Employee Application
Last 4 numbers of your SSN:
Salutation:
v
*First Name:
Middle Initial:
*Last Name:
Nickname:
Address:
* City:
* State:
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* Zip:
*Home Phone:
Enter only numbers, area code first:
Cell Phone:
Enter only numbers, area code first:
Other Phone:
Enter only numbers, area code first:
Email:
In case of emergency, notify name:
Emergency Phone:
Enter only numbers, area code first:
Check if you are legally authorized to work in the United States:
* How did you hear of us:
v
 
* What position are you applying for:
Date available for work:
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Minimum rate per hour:
Days you are available to work full-time:
 
What shifts you are available to work:
Preferred Shift:
What times are you available to work from:
   
To:
   
Checking the below boxes indicates YES:  
Do you have transportation:
Will you accept a same day assignment:
Will you accept a long term assignment:
Are you available part-time:
Are you available full-time:
Are you available temp-hire:
Are you available direct-hire:
 
City 
Yes 
Brookville
Clark County
Darke County
Dayton Suburbs East
Dayton Suburbs North
Dayton Suburbs South
Dayton Suburbs West
Fairborn
Franklin
Greene County
Miami County
Montgomery County
Piqua
Prebble County
Shelby County
Sidney
Springfield
Tipp City
Troy
Urbana
Vandalia
Warren County
Westbrook

Skill Title 
Yes 
[Collapse]Skill Set: 0010 DRIVER
 License
 CDL-A
 CDL-B
 CDL-C
 Tractor Trailer
 Delivery Truck
 Delivery Van
 Automatic
 Clutch
[Collapse]Skill Set: 0010 EQUIPMENT
 Backhoe
 Bulldozer
 Outside Forklift
 Crane
 Drill
 Saw
 Nail Gun
 Jack Hammer
[Collapse]Skill Set: 0010 MAINTENANCE
 Building Repair
 Machinery Repair
 FloorCare
 Landscape
 Lawncare
 Hotel Cleaning
 Janitorial
[Collapse]Skill Set: 0010 SKILLED
 Welder
 Machinist
 Demolition
 Supervisor
 Carpenter
 Construction
 Plumber
 HVAC
 Electrician
 Mechanic
 Painter
 Flagger
 Mover
 Laundry
 Road Crew
 Digger/Raker
 General Labor
 Milwright
 Concrete
[Collapse]Skill Set: 0010 SUPPLIES AVAILABLE
 Hard Hat
 Tools
 Safety Glasses
 Steel Toe Work Boots
 Fluorescent Vest
 Gloves
[Collapse]Skill Set: 0010 WAREHOUSE
 Computer Skills
 Receiving
 Shipping
 Load/Unload
 Hand Jack
 Forklift
 Stand Up
 Sit Down
 Cherry Picker
 Inventory
 Order Selector
[Collapse]Skill Set: 0999 FACTORY
 Mechanical Assembler
 Electronic Assembler
 Solderer
 Inspector
 Picker/Packer
 Quality Control
 Machine Operator
 Production Line
 Production Cell
 PC Board Assembler

Enter as much information as you can. More details will help us better serve you.
(Salary/Pay per hour: NOT REQUIRED in CA, DE, MA, OR, or NYC)

Previous Employment #1

Dates of employment: From: To:
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v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:

Previous Employment #2

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:
   

Previous Employment #3

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:

Previous Employment #4

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:
 

Temporary Employment

FIRM # 1

FIRM # 2

Firm name:
Address:
City, State, Zip:
v
Please list at which clients you were placed, job category, and to whom you reported. Please share your thoughts on the agency and your assignment:
Firm name:
Address:
City, State, Zip:
v
Please list at which clients you were placed, job category, and to whom you reported. Please share your thoughts on the agency and your assignment:
 

High School Education

Name of high school:
High school degree:
High school diploma/certificate:

Business or Other Education

Name of school/program:
School/program degree:
School/program diploma/certificate:

College Education

Name of college:
College degree:
College diploma/certificate:
               
      I hereby authorize BarryStaff Inc. and all former employers, and others given by me as reference, to answer all questions and to give all information in connection with this application or in any way concerning me, and it is understood and agreed that any misrepresentation (including omission of information) by me in this application will result in cancellation of the application and/or immediate termination of employment with BarryStaff Inc. I agree, if employed by BarryStaff Inc., that if ever I make claims against you for personal injuries, upon your request I shall submit to drug screens and examinations by physicians of your selection. Your employment of me may be terminated by BarryStaff Inc. at any time without any liability to me except for wages and salary as have been earned by me at the date of such termination. I understand that it is my responsibility to notify you of my availability on a weekly basis at a minimum, and if I do not, I will be considered unavailable for work.
  


Submit Your Application


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