We Need Professionals! All persons entered in our domestic registry and information obtained in this form will be held in strict confidence, subject to applicable law. We will not discriminate because of sex, age, race, disability, religion, ethnicity, marital status, ancestry, or place of origin.

Application Date *

Please select position for application *

Personal Information

Full Name *

DOB *

Email *

Street Address *

Street Address Line 2 ( Apt #)

City *

State *

Potal Code *

Daytime Phone Number *

Are You Legally Eligible to Work in the U.S.? *

Do you have a valid driver's license? *

Have you been convicted of a felony or been incarcerated in connection with a felony? If, yes, please explain. *

General Information & Availability

Have you applied with us in the past? *

How did you hear about the position? *

Date You Are Available To Work *

WORK HISTORY / EXPERIENCE

Please list your 3 most current work history/experience

Employer's Name (Most current) *

Position Held *

Supervisor's Name *

Telephone *

Start Date *

End Date *

Reason for Departure *

Duties *

May we contact this employer? (Please select one) *

If No, please provide reason why not

(2) Employer's Name

(2) Position Held

(2) Supervisor's Name

(2) Telephone

(2) Start Date

(2) End Date

(2) Reason for Departure

(2) Duties

(2) May we contact this employer? (Please check one)

(2) If No, reason why not

(3) Employer's Name

(3) Position Held

(3) Supervisor's Name

(3) Telephone

(3) Start Date

(3) End Date

(3) Reason for Departure

(3) Duties

(3) May we contact this employer? (Please check one)

(3) If No, reason why not

U.S. EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

(Completion is voluntary and will not subject you to adverse treatment)

LAMPS provides equal employment opportunities to applicants and employees without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability. Employment decisions are made on the basis of job-related criteria without regard to race, ethnicity, color, religion, sex, sexual orientation, gender identity, marital status, age, genetic information, national origin, disability, military, or veteran status, or any other classification protected by applicable law. We invite all applicants to voluntarily self-identify their race, ethnicity, and gender. Submission of the information on this form is strictly voluntary and refusal to provide it will not subject you to any adverse treatment. Information obtained will be retained in a confidential file and separate from personnel records. If you want more information about any of the sections, please check with a company representative.

Gender

Race

SELF-IDENTIFICATION OF VETERAN STATUS

(Completion is voluntary and will not subject you to adverse treatment)

Please select one of the below if you identify with the follow: (1) Disabled veterans – A veteran who served on active duty in the U.S. military and is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or was discharged or released from active duty because of a service-connected disability; (2) Recently separated veteran – A veteran separated during the three-year period beginning on the date of the veteran's discharge or release from active duty in the U.S military, ground, naval, or air service; (3) Active duty wartime or campaign badge veteran – A veteran who served on active duty in the U.S. military during a war, or in a campaign or expedition for which a campaign badge was authorized under the laws administered by the Department of Defense; (4) Armed forces service medal veteran – A veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded. If you believe that you belong to any of the categories of protected veterans, please indicate by making the appropriate selection.

Veteran Status

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past.

How do you know if you have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Autism Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS Blind or low vision Cancer Cardiovascular or heart disease Celiac disease Cerebral palsy Deaf or hard of hearing Depression or anxiety Diabetes Epilepsy Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome Intellectual disability Missing limbs or partially missing limbs Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Disability Status

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Consent & Agreement

False information will cause removal from our registry.I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if this company at anytime learns of falsification or material omission in the information provided on this application form and related documents. You may contact my former employers. All references are hereby authorized to release all information which they may have relevant to my employment with them. I hereby release LAMPS Staffing , its affiliates, successors, and assigns, and all references from any liability that might be claimed because of information provided by such references. I agree that I will follow all LAMPS Staffing policies, rules, and procedures. I understand that LAMPS Staffing reserves the right to add, change, and/or delete any policies, procedures, work rules, and/or benefits at anytime. I agree to make myself available for random drug testing.

Signature *

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