Employment Application


Original Hire Date
Original Hire Date
(last, first, middle)
Address
Address
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
Emergency Contact Address
Emergency Contact Address
Yes/No
Yes/No
Yes/No
If different
Yes/No
Yes/No
(date, place, offense(s), disposition)
Yes/No (Bond: An insurance contract in which an agency guarantees payment to an employer in the event of unforeseen financial loss through the actions of an employee.)
Yes/No
Yes/No
(date, place, offense(s) charged, disposition, etc.)
Yes/No
Yes/No Note: Answering "Yes" to any of these questions may not necessarily disqualify you from the position desired. Each action and explanation will be weighed/considered in the relationship to the underlying facts and circumstances of the position for which you are applying.
Yes/No
(include by whom, when and for what)
Yes/No
Yes/No
Include date, location, description, and result of all violations.
Include: 1. Number of years attended 2. School Name 3. Location (City/State) 4. Major/Degree
(List in reverse chronological order; do not omit any jobs.) Include: 1. Date From/To (mm/yy-mm/yy) 2. Company Name, City, State 3. Supervisory Name and Phone # 4. Job Title and Duties 5. Reason for Leaving
Certification Statement and Agreement *
Certification Statement and Agreement
I certify that all of the facts and information listed on this form and other employment documents are true and complete. I understand that any false, incomplete or misleading information given by me, regardless of when it is discovered, is sufficient cause for rejection of my application or termination. I hereby authorize Landrum Professional and my jobsite employer to investigate all statements contained on this form, to interview references and previous employers, and to obtain a report from a consumer-reporting agency to be used for employment purposes in accordance with the Fair Credit Reporting Act. I authorize Landrum Professional and my jobsite employer to conduct criminal and employment background inquiries prior to and at any rime during my employment I authorize all references and previous employers to give Landrum Professional and my jobsite employer all information and opinions concerning my previous employment and me. I release all such parties from any liability that may arise from furnishing such information to Landrum Professional and my jobsite employer, including. but not limited to, any liability for defamation or invasion of privacy. I understand that satisfactory background checks are a condition of initial and continued employment. If I am employed by Landrum Professional, I understand and agree that I will be assigned to a jobsite employer contracting with Landrum Professional; that I will be required to comply with the policies set forth in Landrum Professional employee handbook and any handbooks and regulations of the jobsite employer. In the event of conflict between the handbooks and policies of Landrum Professional and the jobsite employer, Landrum Professional's handbooks shall prevail. I understand that if I am hired, I will not be considered to be working for Landrum Professional until I have satisfied all post-offer medical inquiries and examinations. I also understand that I will be required to serve a (90) day probationary period, and that I may be discharged at the end or any time during that period of unsatisfactory work performance or any other reason. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my probationary period, at the option of Landrum Professional, my jobsite employer, or myself. Any prior valid written contracts and agreements, including non-compete or non-solicitation agreements, with my jobsite employer are hereby affirmed by me and shall continue to remain in full effect as provided therein during my co-employment with my jobsite employer and Landrum Professional. Other than such prior agreement, no supervisor or other representative of my jobsite employer or Landrum Professional other than the President or authorized officers of my jobsite employer or Landrum Professional (in writing), has any authority to enter into any agreement with me for the employment for any specified period of time, or to make any agreement contrary to the foregoing. If Landrum Professional employs me, I understand that this is my responsibility to keep an accurate and complete record of my hours worked each day. I understand and agree that Landrum Professional’s liability for payroll is limited to payroll hours and information Landrum Professional timely receives from my jobsite employer and me. In the event that Landrum Professional is not timely paid by my jobsite employer for my compensation and benefits, any claims I have against Landrum Professional shall be limited to minimum wage for hours worked, and all remaining pay and benefit claims shall my solely against my jobsite employer. If Landrum Professional is required to pay me and is unable to timely obtain reimbursement from my jobsite employer, I assign to Landrum Professional my rights to any salary claims that have been satisfied by Landrum Professional. I understand that I am only eligible to participate in those Landrum Professional benefit plans that are specifically offered to employees at my jobsite through mutual agreement of Landrum Professional and my jobsite employer. I further understand and voluntarily agree, as a condition of employment or my continued employment, that I may be requested by Landrum Professional to submit a urinalysis or other drug screen test, and that my failure to take such test(s) when requested to do so, or unsatisfactory results, will disqualify me from consideration for employment, or if I am then employed, may result in my immediate dismissal. I acknowledge and agree that if at any time I am subjected to any type of discrimination and/or harassment, or have any other employment-related disputes or claims, I will contact Landrum Professional’s Human Resources representative immediately to obtain assistance in the resolution of such matters, and agree to allow Landrum Professional and my jobsite employer the opportunity to resolve any such claim or issue prior to seeking resolution through other means. I certify that I have read, fully understand and agree with the foregoing certification statement and agreement.
Today's Date *
Today's Date