Personal Information

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    Provide the name, relation, and the phone number of emergency contact.
    Please list all that software you have experience with.
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    Do you object to an employment background check, including credit and criminal history?
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    Do you object to a drug test?
    Pre-Offer Invitation to Self-Identify Protected Veteran Status
    This employer is a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended (Section 4212), which requires government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.
    Our affirmative action policy prohibits discrimination and requires us to take affirmative action to employ and advance in employment qualified protected veterans at all levels of employment. The below invitation is made pursuant to this policy.
    Disclosure of this information is voluntary and refusing to provide it will not subject you to any adverse treatment. The information will be used only in ways that are consistent with Section 4212. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and
    (iii) government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
    Do you identify as one (or more) of the following protected veteran categories? Please check the appropriate box below.
    Disabled Veteran: (i) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs; or (ii) a person who was discharged or released from active duty because of a service-connected disability.
    Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
    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 medal was awarded pursuant to Executive Order 12985.
    Active Duty Wartime or Campaign Badge Veteran: a veteran who served in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
    Self-Identification of Race/Ethnicity and Gender
    Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual's terms and conditions of employment, because of such individual's race, color, religion, sex, or national origin.

    This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their race/ethnicity and gender. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes.

    If you choose not to self-identify your race/ethnicity and gender at this time, the federal government requires this employer to determine this information by visual survey and/or other available information.

    For civil rights monitoring and enforcement purposes only, all race/ethnicity and gender information will be collected and reported in the seven categories identified below. The definitions for each category have been established by the federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below.
    In addition to our affirmative action obligations, we value all forms of military service. If you are not a protected veteran as described above but would like to disclose your status as a member of the military, you may do so below. Are you currently serving, or have you served, in the Armed Forces of the United States of America (including the Reserves and National Guard)?
    Effective immediately, all employees must obtain treatment of work-related injuries from:
    Concentra Medical Centers
    (Multiple Locations)
    HealthOne Occupational Medical Centers
    (Multiple Locations)
    In the event of a life-or-limb-threatening emergency, call 911. The insured employee will be sent to the nearest medical emergency facility. The medical provider information above must complete all follow-up appointments/care.
    In the event on an after-hours, non-emergency injury, the provider should be called at (866) 944-6046 (Concentra) or 1-877-HEALTHONE (HealthOne Occupational Centers) for access information or treatment instructions.
    If an unauthorized medical provider treats an employee, the employee will be responsible for payment of said treatment.
    All employees must sign below, acknowledging this company policy. Your signature confirms you have read, are fully aware of and completely understand Hire Connection's policy regarding medical treatment for work-related injuries and illnesses.
    I acknowledge that I have received this Handbook electronically and I have been fully oriented in the office. Further, I understand that I must contact Hire Connections within 3 days of the end of my assignment. If not, understand that I voluntarily terminate/resign my employment with Hire Connections. I understand that my employment at Hire Connections is at will and may be terminated at any time by me or Hire Connections without notice.
    I have read and understand the guidelines with in the Hire Connections Handbook and understand the guidelines are not a contract and impose no legal obligation of any kind on Hire Connections.
    I agree that I will not share any information regarding openings, hiring authority's names, company names or any other information deemed confidential or proprietary with other parties od which might jeopardize Hire Connections or client companies.

    Employee Hand Book


    I hereby certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired.

    I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

    I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

    Digital Signature