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Resume Text
Contact Information
Check one *	Mr   Ms
First Name *		Last Name *
Address *		City *
State *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip *
Email *		Preferred Name *
Phone *	XXX-XXX-XXXX	Alternate Phone	XXX-XXX-XXXX
SSN *	Do not enter spaces or dashes - i.e. 111223333	Verify SSN *	Do not enter spaces or dashes - i.e. 111223333
Note: Your social security number is necessary for tracking purposes. We cannot complete your application without it. However, we have taken every precaution to ensure the security of this information.
Password
Passwords must be a minimum of 6 characters and have at least 2 numbers and 2 letters. Passwords ARE case-sensitive.
Password *		Confirm Password *
ADDITIONAL INFORMATION
Date Available	MM/DD/YYYY	Desired Salary Range *	$10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $60,000 $60,000 - $70,000 $70,000 - $80,000 $80,000 - $90,000 $90,000 - $100,000 $100,000 - $110,000 $110,000 - $120,000 $120,000 - $130,000 $130,000 - $140,000 $140,000 - $150,000 over $150,000
Have you ever applied to any of our offices before? *		Yes   No
Have any of your friends and family worked for the Employer, now or in the past? *		Yes   No If YES, please explain the circumstances.
Are you 18 or older? *		Yes   No
When you interview with our service, will you be able to provide the following valid documentation?
Identity (Picture ID) *		Yes   No
Eligibility to Work in the US *		Yes   No
Information provided is subject to verification with the Social Security Administration and/or the US Citizenship and Immigration Services.
List all other names by which you've been known.
Please explain any additional information relative to a change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record?
Have you been a temporary with another service before? * Yes   No   If YES, we will ask you to complete a Temporary Experience Supplement during your interview.
List all languages spoken other than English. Hold the Ctrl key (on a PC) or the Command key (on a Mac) and click to select multiple languages.		Mandarin Chinese Cantonese Chinese Chinese French German Hmong Italian Japanese Korean Monolingual Spanish Hindi Other Punjabi Russian Spanish Tagalog Vietnamese
Where Did You Hear About Us *		CareerBuilder.com Company Website Craig's List Customer Referral Facebook Google Indeed.com Job Fair Local church/community center Local college Monster.com Radio Advertisement Referred by Friend Saw flyer posted Simply Hired Walk-In Yellow Pages
Assignment Information
Asmt No.
WORK PREFERENCES
Type of work desired *
Shifts available *	1st  2nd  3rd  Weekends	Hours Available *	Full-time  Part-time
Minimum Pay Rate $ *	$XX.XX per hour	Miles willing to travel? *
LEGAL QUESTIONS
Have you been discharged or asked to resign from any job? *  Yes   No If YES, please explain the circumstances.
Have you ever been reprimanded, suspended with or without pay, or terminated for fighting on the job, whether or not it was your fault? *  Yes   No If YES, please explain.
Will any of your work references disclose/reveal anything negative? *  Yes   No If YES, please explain.
If a driver license is required for the position for which you are applying, do you have a valid license? *  Yes   No License No.   Exp. Date  State of Issue  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Since you are applying for a position which may require driving, have you been cited for a traffic violation of any kind within the past 7 years? * Yes   No If YES, please give date and details.
Have you ever plead guilty, "no contest", or been convicted of a felony or misdemeanor crime since the age of 18, including such moving violations as driving under the influence of a drug or alcohol, which were not later expunged? (CA Only - Do not disclose convictions for marijuana possession over two (2) years old or offenses for which you were referred to, and participated in, any pre-trial or post-trial diversion program. GA Only - Do not disclose information pertaining to any "first offender discharge" CONN Only - Do not disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. HI Only - You will only have to answer this question if you receive a conditional offer of employment. MASS Only - Applicants for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to an inquiry relating to prior arrests, criminal court appearances, or convictions. In addition, Mass. Applicants for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. Mass. applicants should not disclose information regarding first-time misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace. Finally, Mass. applicants should not disclose convictions for other misdemeanors where the date of conviction or the end of any period of incarceration was more than five years ago unless there have been subsequent convictions within those five years. ) * Yes   No If YES, please give dates and details.
Are you currently out on bail, or on your own recognizance pending trial, for an arrest? (NOTE: Answering "YES" to the above questions does not constitute an automatic bar to employment. Each case will be determined on its own merits.) * Yes   No If YES, please give dates and details of such arrest.
Are you currently using illegal drugs? * Yes   No If YES, which illegal drugs have you recently used?
If YES, when did you recently use each of these drugs?
EDUCATION Please enter your highest level of education.
School Name *		List any special trade or vocational schools attended:
Location (City, State) *		List any professional or vocational certificates, licenses, or registrations that you currently hold or have held in the past:
Major/Subject *		G.P.A.
Describe any specialized training, apprenticeship, skills, extracurricular activities, honors, scholarships, appointments, awards, or special recognition that you have received:
Diploma/Degree *	Associate of Arts Associate of Science Bachelor of Arts Bachelor of Science Attended less than one yr of college or trade school Completed 1 year of college Completed 2 years of college Completed 3 years of college Completed 4 years of college Certification Doctorate Degree Completed High School Masters Degree Masters Business Administration G.E.D. Working on G.E.D. Did not complete high school
EMPLOYMENT HISTORY List the names of your past 3 employers, or last 10 years worked, whichever is longer, in chronological order with present or last employer first. Be sure to account for all periods of time, including military service and any period of unemployment of more than 3 months. If self employed, supply firm name and business references.
Company Name *
City *		State *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Supervisor *		Phone *	XXX-XXX-XXXX
Reason for Leaving *	Absenteeism Additional job needed Assignment given to another branch office Assignment over Better opportunities Business closed Child Client ended assignment Company moved had to reenter assignments Converted to regular staff Could not work hours assigned Department change Did not pass background check Duties Employee voluntarily quit Environment Got lost on way to job Illness Inadequate performance Job injury Lack of training Layoff Location Low pay Low wages Management Mistake/duplicate assignment Moved away No show Not qualified Perm position Poor match with client Retired Schedule conflict Short term leave/vacation Showed up but was not selected for work Still working there Tardiness Temp changed mind Terminated Terminated because i9 expired Terminated because of invalid ss# Transportation Unexcused reasons Walked off the job Went back to school
Starting
Date *	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr *	$XX.XX
Ending
Date	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr	$XX.XX
Title *
Job Duties *
May we contact this employer? * Yes   No   If NO, please explain.
Employment Gap of more than 3 months (if any). Please Explain Fully.
Company Name
City		State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Supervisor		Phone	XXX-XXX-XXXX
Reason for Leaving	Absenteeism Additional job needed Assignment given to another branch office Assignment over Better opportunities Business closed Child Client ended assignment Company moved had to reenter assignments Converted to regular staff Could not work hours assigned Department change Did not pass background check Duties Employee voluntarily quit Environment Got lost on way to job Illness Inadequate performance Job injury Lack of training Layoff Location Low pay Low wages Management Mistake/duplicate assignment Moved away No show Not qualified Perm position Poor match with client Retired Schedule conflict Short term leave/vacation Showed up but was not selected for work Still working there Tardiness Temp changed mind Terminated Terminated because i9 expired Terminated because of invalid ss# Transportation Unexcused reasons Walked off the job Went back to school
Starting
Date	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr	$XX.XX
Ending
Date	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr	$XX.XX
Title
Job Duties
May we contact this employer? Yes   No   If NO, please explain.
Employment Gap of more than 3 months (if any). Please Explain Fully.
Company Name
City		State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Supervisor		Phone	XXX-XXX-XXXX
Reason for Leaving	Absenteeism Additional job needed Assignment given to another branch office Assignment over Better opportunities Business closed Child Client ended assignment Company moved had to reenter assignments Converted to regular staff Could not work hours assigned Department change Did not pass background check Duties Employee voluntarily quit Environment Got lost on way to job Illness Inadequate performance Job injury Lack of training Layoff Location Low pay Low wages Management Mistake/duplicate assignment Moved away No show Not qualified Perm position Poor match with client Retired Schedule conflict Short term leave/vacation Showed up but was not selected for work Still working there Tardiness Temp changed mind Terminated Terminated because i9 expired Terminated because of invalid ss# Transportation Unexcused reasons Walked off the job Went back to school
Starting
Date	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr	$XX.XX
Ending
Date	January February March April May June July August September October November December     2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950	Wage Per Hr	$XX.XX
Title
Job Duties
May we contact this employer? Yes   No   If NO, please explain.
Employment Gap of more than 3 months (if any). Please Explain Fully.
REFERENCES List three additional business/professional references who have known you for at least one year. DO NOT LIST PERSONAL REFERENCES.
Reference 1 Name Business Phone Address Years Acquainted XXX-XXX-XXXX Reference 2 Name Business Phone Address Years Acquainted XXX-XXX-XXXX Reference 3 Name Business Phone Address Years Acquainted XXX-XXX-XXXX
EMERGENCY CONTACTS
Name		Phone	XXX-XXX-XXXX
Name		Phone	XXX-XXX-XXXX
PAYROLL
Please check how you would like your payroll handled upon hire. *
Directly deposited to my bank account. (Direct Deposit form must be submitted to the Employer.) Deposited onto a pay card. (Enrollment form must be submitted to the Employer.)
SKILLS
Please click on the skills that best describe your experience. Opportunities to expand your abilities may be available at the time you are considered for a position. *
CLERICAL INDUSTRIAL ACCOUNTING BANKING/MORTGAGE CLERICAL COMPUTER APPLICATIONS CUSTOMER SERVICE DATA ENTRY HUMAN RESOURCES INSURANCE LEGAL MARKETING/SALES MEDICAL/DENTAL PURCHASING RECEPTIONIST SECRETARIAL ACCOUNTING Accounting Clerk Accounting Manager Accounts Payable Accounts Receivable ADP Experience Bank Reconciliation Bookkeeper Bookkeeper - Full Charge Cashier Controller Cost Accountant CPA Credits/Collections Financial Analyst Financial Statements General Ledger Junior Accountant Payroll Profit/Loss Taxes Accounting Trial Balance BANKING/MORTGAGE Bank Teller Banking/Finance Manager Escrow Loan Auditor Loan Funder Loan Officer Loan Processor Mortgage Title Mortgage Underwriter Notary Public CERTIFICATIONS Governmental Security Clearance ISO CLERICAL Collator Document Control Filing Mailroom Office Manager COMPUTER APPLICATIONS ACT! Adobe Illustrator Adobe PageMaker/Indesign Adobe Photoshop Corel Draw Dreamweaver FileMaker Pro FoxPro GroupWise Internet/Web Browser Lotus 1-2-3 Lotus Notes MAS Accounting Microsoft Access Microsoft Excel Microsoft Front Page Microsoft Outlook Microsoft Power Point Microsoft Project Microsoft Publisher Microsoft Windows Microsoft Word Norton Utilities Oracle Database Peachtree Accounting Quickbooks Quicken SQL Database Visio Word Perfect CUSTOMER SERVICE Call Center In Bound Customer Service Manager Dispatcher Help Desk Host/Hostess Retail Customer Service Translator/Interpreter Waiter/Waitress DATA ENTRY 10-Key By Sight 10-Key By Touch Alpha Numeric HUMAN RESOURCES Benefits Generalist HR Assistant Human Resources Manager Recruiting Training and Development Workers Compensation INSURANCE Claims Examiner Insurance Manager Insurance Underwriter Insurance Underwriting Assist. LEGAL Calendaring Court Filing File Indexing Legal Secretary Litigation Secretary Paralegal MARKETING/SALES Conventions Demonstrations Marketing Assistant Marketing Manager Marketing Research Project Coordinator Sales Inside Sales Manager Sales Outside Shopper Surveys Telemarketing MEDICAL/DENTAL Medical Billing Medical Coding Medical Office Manager Medical Receptionist Medical Transcription PURCHASING Buyer Expediter Planner Purchasing Assistant Purchasing Manager RECEPTIONIST PBX Operator Switchboard SECRETARIAL Administrative Assistant Dictaphone Executive Secretary Shorthand Speedwriting Typing COMPUTER PC OPERATION CONSTRUCTION DRIVERS ELECTRICAL ASSEMBLY FOOD SERVICE FORKLIFT GENERAL LABOR MACHINE OPERATOR MAINTENANCE MECHANICAL ASSEMBLY PRODUCTION WAREHOUSE CERTIFICATIONS CPR Certified First Aid Certified COMPUTER PC OPERATION Fedex Shipping Software UPS Shipping Software CONSTRUCTION Carpenter Electrician HVAC Painting Plumbing Welding Certified Welding Not Certified      Welding Not Certified : ARC Welding      Welding Not Certified : MIG Welding      Welding Not Certified : TIG Welding DRIVERS Class A Commercial License Class A Noncommercial License Class B License Class C License Delivery ELECTRICAL/MECHANICAL ASSEMBLY Assembly Blueprint Reading Calipers Circuit Boards Clean Room Color Codes Crimpers Manual (Board) Microelectronics Micrometers Microscope Mil Spec Soldering Schematics Soldering Surface Mount Soldering Wire Bonding Wire Harnessing Wiring Diagrams FOOD SERVICE Cook Dishwasher Grill Cooking Prep Cooking FORKLIFT Clamp Forklift Certified Electric Pallet Jack Certified Electric Pallet Jack Not Certified Manual Pallet Jack Order/Cherry Picker Certified Order/Cherry Picker Not Certified Reach Truck Certified Reach Truck Not Certified Sit Down Forklift Certified Sit Down Forklift Not Certified GENERAL LABOR Lifting Regularly up to 10 lbs. Lifting Regularly up to 20 lbs. Lifting Regularly up to 50 lbs. MACHINE OPERATOR Bobtail Boring Mill Brake Press Bridgeport Cincinnati CNC Operator CNC Programmer CNC Setup Conventional Machine Operator Conventional Machine Setup Deburring Disco/Dicing Machine Drill Press Engine Lathe Fadal Fanuc General Electric Jig and Fixture Builder Jig Bore Jig Grinder Lathe Machinist Mill Model Maker Mold Maker Mori Seiki Numerical Control (NC) Print Press Operator Prototype Punch Press R & D Sewing Machine Surface Grinder Tool & Die Maker Tool Room Turrett Lathe MAINTENANCE Auto/Truck Mechanic Building/Facility Maintenance Electrical HVAC Hydraulic Janitorial Landscape Machinery Maintenance Pneumatic Sheet Metal Mechanic PRODUCTION Collator Expediter Packing Production Line Quality Control/Inspector WAREHOUSE Cycle Counting Installer Inventory Mailroom Order Puller Picking Pricing/Ticketing Shipping & Receiving Stocking/Stockroom
Have you held either of these positions?		Managerial Supervisor
Legal Acknowledgements APPLICANT'S AGREEMENT AT-WILL I understand that Westaff does not hire everyone who fills out an application for employment and that all applicants must meet certain general hiring criteria set forth by Westaff, such as having the legal right to work in the U.S., appropriate skills, job history, and favorable references. Applicants must also have personal qualities such as being honest, trustworthy, non-violent, and reliable. I understand that Westaff does not discuss hiring or placement criteria or hiring decisions with applicants or employees, and that Westaff does not discuss termination decisions with employees. I understand that my employment at Westaff is on an at-will basis and that I may be terminated at any time, with or without cause, and with or without notice, either at my option or at the option of Westaff. In consideration of my employment, I agree to conform to the rules and standards of Westaff, as amended by Westaff from time to time at their discretion. I further agree that my employment and compensation is for no definite period. Terms and conditions of employment including promotions, change in job duties, locations, and compensation can be changed at the sole discretion of Westaff, at any time, with or without cause, advance notice, or stated reason. Westaff may warn, reassign, suspend, demote, or terminate any employee in their sole discretion, at any time, with or without cause, advance notice, or stated reason. I understand that no employee or representative of Westaff, other than the Chairman & CEO, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement or condition contrary to the foregoing. Further, the Chairman & CEO of Westaff may not alter the at-will nature of this employment relationship unless he signs a written document in which he specifically and clearly indicates the intent to do so. Please initial authorization and consent for AT-WILL section*   VERIFICATION & RELEASE I hereby certify that the information supplied on this application for employment is true and correct to the best of my knowledge, and agree to have any of the statements checked by Westaff, unless I have indicated to the contrary. I authorize Westaff to contact any and all of the references listed (including employers and schools), and I authorize those references to provide Westaff any and all information concerning my previous education and employment and any other pertinent information that any of them may have or know about me. Further, I release all parties, companies, and persons providing such information to Westaff from any liability for any damages that may result from furnishing such information to Westaff as well as from the use or disclosure of such information by Westaff or any of their agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application or during the interview process (regardless of when discovered) may result in my failure to receive an offer or, if I am hired, my immediate termination from employment at any time. I understand that on some jobs I may be offered full-time employment. This may be approved if Westaff is notified prior to my accepting the full-time assignment and after I have completed 720 hours for that client or the number of hours mutually agreed upon by Westaff and the client. I understand that at the end of an assignment it is my responsibility to contact Westaff immediately to report my availability. I will become an employee upon commencing a paid assignment with a client of Westaff. When my assignment with any particular client ends, I will remain an employee of Westaff, however unpaid and not on active duty, and Westaff will continue its efforts to find me a new assignment. The end of any particular assignment with a client does not end my employment relationship with Westaff. My employment relationship with Westaff will end only on the occurrence of one of the following three events: I tell Westaff that I am not interested in additional assignments from Westaff; Westaff tells me that I am not eligible for additional assignments from Westaff; or 14 days pass after the end of my last assignment with a client of Westaff, and Westaff has not offered me a new assignment which I have accepted. I acknowledge that I am not eligible to receive the benefits offered by Westaff's clients to their employees. I also understand that any offer of employment from Westaff is conditional on Westaff receiving satisfactory responses to reference requests, passing a drug screen, and providing satisfactory proof of my identity and legal authority to work in the United States. This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time, you must reapply. Please initial authorization and consent for VERIFICATION & RELEASE section*   DISCRIMINATION AND REPORTING POLICIES Westaff does not discriminate against their applicants or employees in any manner, and cannot and will not tolerate any form of harassment, including sexual harassment, or discrimination of any type, whether based on sex, race, age, national origin, ancestry, religion, sexual orientation, marital status, or physical or mental disability, toward our employees. Westaff is an Affirmative Action and Equal Opportunity Employer. If you believe that you (or another co-worker) have been discriminated against or harassed by a co-worker, supervisor, agent of Westaff, or a customer, you should immediately report the facts of the incident and the names of the individuals involved to the Corporate Human Resources Director, who will promptly investigate all claims and take appropriate action. Call 1-800-688-6162 for a direct line, or 877-LISTEN-0 to reach the legal complaint and counseling hotline. Please initial authorization and consent for DISCRIMINATION AND REPORTING POLICIES section*   MUTUAL AGREEMENT TO ARBITRATE If Westaff and I are unable to resolve any dispute informally, I agree to having the dispute submitted and determined by binding arbitration in conformity with the procedures of the Federal Arbitration Act and the California Arbitration Act (California Code of Civil Procedure section 1280, et. seq.), including section 1283.05 and all other rights to discovery. Such disputes may include but not be limited to any involving breach of contract, fraud, misrepresentation, defamation, personal injury, wages, wrongful discharge, vacation pay, sick time pay, overtime pay, state and federal employment laws, and regulation including but not limited to the Fair Labor Standards Act (including the equal Pay Act), the Civil Rights Act of 1964 as amended, 42 U.S.C. section 1981, the Americans with Disabilities Act, laws prohibiting discrimination by reason of religion, sex, age, color, national origin, handicap, disability, medical condition, marital status or other basis, ADEA, federal and state, state labor code provisions, the Family and Medical Leave Act, the Employee Retirement Income Security Act (ERISA), and any amendments thereto, state unfair competition or unfair business practices provisions, and those claims whether in law or equity, which either party could assert, at common law or under statute, rule, regulation, order of law, whether federal, state, or local, except for those under the National Labor Relations Act, claims for workers' compensation and unemployment insurance, and any other claims precluded from arbitration by law. I agree that such arbitration will be conducted in Santa Barbara, CA. Please initial authorization and consent for MUTUAL AGREEMENT TO ARBITRATE section   AUTHORIZATION AND CONSENT FOR DRUG SCREENING I consent to a pre-employment test to detect the use of illegal or controlled substances, alcohol, or prescription medication without a prescription. I consent to provide a specimen of my urine and/or blood or hair as may be requested in conformity with Westaff's policies and procedures. I certify that urine submitted for such a drug screen will be my own. I understand that I have a right to receive a copy of this authorization. I understand that Westaff may require a post-accident screening to test for illegal drugs or controlled substances, alcohol, or prescription medication without a prescription when a work-related accident is reported, in accordance with Westaff's policy, and I consent to such a drug screening. I consent to the release of drug screen results to Westaff I also authorize any physician, hospital or clinic who may have examined me previously for drug or substance abuse to release to Westaff a complete record of the findings, results or opinions. I understand and agree that the results of my drug screens may be used in determining my employment eligibility. If I refuse to sign this consent, fail to take a pre-employment or accident-related drug screen, or fail any portion of the test, I will not be considered for employment, or if employed, I will be terminated. I understand and agree that Westaff may release the results of my pre-employment and/or post-accident drug screens to the State Unemployment Department if a claim for unemployment insurance is filed by me or on my behalf. I agree to hold all parties harmless and not to sue in connection with any aspect of drug screen testing or its effect on my employment status. I understand that if I have any questions about the meaning of the provisions in this authorization and consent or the drug screens, they will be answered on request. Please initial authorization and consent for AUTHORIZATION AND CONSENT FOR DRUG SCREENING section*   AUTHORIZATION FOR RELEASE OF EMPLOYMENT/MEDICAL RECORDS For the duration of my employment, I give permission to Westaff to furnish and release to its Workers' Compensation carrier and/or administrator, or any representative thereof, the following information: 1. All medical records pertaining to examinations, treatments, or consultations, including but not limited to, billing records; x-rays and reports; history records; diagnosis and prognosis records; nurses' and doctors' notes and all reports and any psychiatric or mental health records; and all reports relating to diagnosis, care and treatment for drug and alcohol abuse. 2. All employment records pertaining to employment with Westaff and any previous employer, including but not limited, to personnel records, payroll records, medical records, and time records. I understand that the information obtained will be used by Westaff's Workers' Compensation carriers and/or administrators for the evaluation and processing of any claims for Workers' Compensation benefits as a result of any work-related injuries. I do not give permission for any other use or re-disclosure of this information. This Authorization is valid until my claim has been accepted or denied, but in no event beyond one year from the date of my injury. A photocopy of this Authorization is as effective as the original. I understand that I am entitled to a copy of this Authorization. Please initial authorization and consent for AUTHORIZATION FOR RELEASE OF EMPLOYMENT/MEDICAL RECORDS section*     I hereby certify that the information supplied on this application for employment is true and correct to the best of my knowledge, and agree to have any of the statements checked by Westaff, unless I have indicated to the contrary. By signing I acknowledge that I have read and understood all of the above statements. Signature* Please enter your name in the same format that you sign your name Signature Date* (i.e. MM/DD/YYYY)