Application Forms

Applicant's Statement
Employment Application
I-9
VA-4
W-4

Employment Application

Personal Information
First Name	Middle Initial	Last Name
SSN
Address
City	State	Zip Code
List any addresses, other than your current one, in which you have resided in the last 2 years, including dates
Primary Phone Number	Alternate Phone Number
Work Eligibility and Availability
Indicate when you are available for work Any Shift Days Nights Weekends Part Time Full Time
Are you legally eligible for work in the United States? Yes No
Do you have a car for transportation? Yes No
Have you ever been convicted of a criminal offense (Felony or Misdemeanor)? Yes No
If "Yes" list date, charge, and current status
Are you currently on probation? Yes No
If currently on probation, please list Parole Officer's name and phone number
Have you ever worked at Canon, Industrial Resource Technologies, or CVO? Yes No		As a direct member? Yes No
If employed through an agency, which one?	Supervisor name and date
Are you 18 years or older? Yes No
How did you learn about us?
Education and Employment History
Personal / Professional References (do not include family members or past supervisors) 1. 2. 3.
Education History
High School(s) attended		Highest grade achieved
College(s) attended		Years Completed
Other Technical / Trade School(s)	Completed Y N	Diploma Y N
Employment History
Employer 1
Employer Name		Phone
Address
City	State	Zip
Start Date	End Date	Pay Rate
Reason for leaving
Job Title	Duties Performed
Is this a Staffing company? Yes No	If yes, what companies were you assigned to?
Employer 2
Employer Name		Phone
Address
City	State	Zip
Start Date	End Date	Pay Rate
Reason for leaving
Job Title	Duties Performed
Is this a Staffing company? Yes No	If yes, what companies were you assigned to?
Employer 3
Employer Name		Phone
Address
City	State	Zip
Start Date	End Date	Pay Rate
Reason for leaving
Job Title	Duties Performed
Is this a Staffing company? Yes No	If yes, what companies were you assigned to?
Work Experience Please fill out only the section corresponding to the type of work you are applying for.
Light Industry / Labor / Ship Repair
Assembly Experience Yes No	If yes, what did you assemble and for how long?
Food Service Dishwasher Cook Setup Server Other
Have you driven a forklift? Yes No	If yes, what type of forklifts have you driven?
Have you ever moved furniture professionally? Yes No	If yes, where and for how long?
Have you ever done commercial landscaping / groundskeeping? Yes No	If yes, what type of equipment was used?
Have you ever operated any type of machinery? Yes No	If yes, what type of machinery?
Have you ever performed picking / packing / production duties? Yes No	If yes, where and what type of item?
Have you ever done commercial janitorial / housekeeping work? Yes No	If yes, where and for how long?
Have you ever loaded or unloaded trucks? Yes No	If yes, what type?
Have you ever done construction, residential or commercial? Yes No	If yes, by what means?
Have you ever done shipyard labor? Yes No
Office Clerical / Administrative Have you ever performed any of the following duties?
Accounting Yes No	If yes, where and for how long?
Type of accounting	Number of employees
Banking Yes No	Type of banking	Company
Are you willing to work single-day jobs? Yes No
Collections Yes No	If yes, where and for how long?
Customer Service Yes No	Type of customer service
Data Entry Yes No	If yes, where and for how long?	Speed?
General Office Work Yes No	Type of office work Switchboard Reception Fax Copiers Filing
Human Resources Yes No	If yes, where and for how long?
Secretarial Tasks Yes No	If yes, where and for how long?	Typing Speed
Telemarketing Yes No	Type of telemarketing
Computer Software Proficiency Yes No	If yes, list programs

Production Support Services

11834 Canon Blvd. Suite M

Newport News, VA 23606

757-599-5959

info@pssinc.net

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Application Forms

Employment Application

Personal Information

Work Eligibility and Availability

Education and Employment History

Education History

Employment History

Employer 1

Employer 2

Employer 3

Work Experience

Light Industry / Labor / Ship Repair

Office Clerical / Administrative