Personal Information Name *
First Last Address Email
Home Phone Cell Phone DL # * Position Applying For * EPA Certified Special Skills or Language Education List * A conviction will not automatically disqualify an applicant for a particular job. The type and seriousness of the crime, the frequency of the violation(s), your age at the time of conviction, the date of conviction, time elapsed since the conviction, completion of any sentence, along with your entire work and educational history, as well as employment references and recommendations, will be considered. Have You Ever Been Arrested or Convicted of a Crime? *
If so please explain in the box below. This includes deferred adjudication.
Year / Charges Conviction If so, please explain Employment History
(Starting with Most Recent)
Job # 1 Name of Company * Name of Supervisor * Position Phone Hourly Rate Reason For Leaving * Rehire-able Start Date * Leave Date * Job # 2 Name of Company Name of Supervisor Position Phone Hourly Rate Reason For Leaving Start Date Leave Date Job # 3 Name of Company Name of Supervisor Position Phone Hourly Rate Reason For Leaving Start Date Leave Date Job # 4 Name of Company Name of Supervisor Position Phone Hourly Rate Reason For Leaving Start Date Leave Date Employment Agreement with Platinum Apartment Staffing
Please Initial each Numbered Paragraph
1) I understand that I could receive an employment evaluation on each job assignment * 2) I understand that I will not be permitted to be absent from temporary assignments to interview for other employment. I understand that I will arrange to be interviewed on my own time, before or after my regular work hours. I further understand that I may be permitted to schedule an interview during my lunch period if I have obtained the prior approval of PAS. * 3) The following actions are considered job abandonment and immediate Termination in the event that I (a) Fail a drug screen give either by PAS, or by a client of PAS for purposes of full time or temporary employment, (b) walk off of a job before the end of my shift or (c) fail to return to complete my temporary assignment without notifying and obtaining approval from PAS. I understand by these actions, that any monies owed to me will be reduced to minimum wage for that job assignment. * 4) I understand that I am responsible to CALL IN DAILY for availability to PAS. In the event that I fail to notify PAS daily, I will be considered to have left voluntarily without work-connected reason, and PAS may deny unemployment benefits. * 5) I understand that equipment or supplies that are supplied by the client are not for my personal use. If Assigned to a temporary position by PAS I understand that I will be required to work a total of 160 consecutive hours on a temporary basis at that property prior to conversion to a permanent position unless a placement fee is paid. If the client refuses to pay the placement fee and I accept the position, I understand that I will be required to pay the fee for the position I am filling. * 6) understand that my payroll won't be processed without an authorized signature from client(s) of PAS. * 7) I understand that PAS is not responsible for my timesheet collection. Without a timesheet we will be unable to process your payroll. PLPASE MAKE SURE YOUR TIMESHEET IS COLLECTED. Timesheets are due Monday, no later than 12:00 PM. If you are not working weekends, then you should fax your timesheet before you leave on Friday. * 8) I understand that i will receive my check on friday in the event I lose my check a stop payment will be issued and I will be responsible for any bank charges. * 9) I understand any assignments that I work on involving Incidents regarding theft of any kind, will result in immediate suspension of pay until the incident is resolved. I further understand that if proven, I will be responsible for the monetary replacement theft(s) items of any kind by way of payroll deductions or prosecution. * Please check the following box to agree to terms. * Signature *
Typing name will be considered electronic signature.
MM slash DD slash YYYY Drug Abuse and Harassment Policy Drug Abuse and Harassment Policy I agree to the policy.
Platinum Apartment Staffing (PAS) has adopted the following Policy to apply to all of its full-time, part-time, and temporary Employees assigned to client companies as well as its corporate staff. This policy is adopted in order to help you fulfill your job-related responsibilities by understanding the company's position on any drug abuse.
For purposes of this policy, the term "drug" includes alcoholic beverages and prescription drugs, as well as illegal inhalants and illegal drugs. It specifically excludes prescription drugs when taken as directed by the employee's doctor. Use of or being under the influence of a "drug" as herein defined is strictly prohibited during working hours, or within 3 hours prior to a scheduled work period. Being under the influence means being affected in any detectable manner or in possession of a "drug" while performing company assigned business or on client company property. Violation can lead to immediate job termination. The company, at this time, does not sponsor a drug abuse training or education program not does it provide company funded or insurance funded rehabilitation programs. Any employee, however that wishes to seek guidance or counseling related to a drug abuse problem should contact PAS. PAS does not at this time mandate drug testing with the exception of circumstances involving a workers compensation injury and claim. However, based on the unique contractual requirements of client companies, PAS reserves the right to universally do so at any time. It is the policy of PAS to maintain a work place that is free of discrimination, including sexual harassment, and expect the full cooperation of all employees and clients in maintaining a professional work environment at all times. Any employee, who believes he or she has been subjected to discrimination or sexual harassment, or has witnessed such conduct, must immediately notify a PAS official. Abusive behavior, verbal or non-verbal shall not be tolerated and I agree to report such behavior to a PAS official immediately. It is recommended that complaints be submitted to PAS in writing to assist in the resolution of any complaint. It is our Policy to investigate complaints promptly and to keep complaints and the result of the investigation confidential to the fullest extent practicable except to extend necessary and fully to investigate and to act on results with an investigation. There will be no retaliation against anyone for reporting discrimination or harassment, or cooperating with such an investigation. Signature *
Typing name will be considered electronic signature.
MM slash DD slash YYYY Background Investiagation for Employment by Platinum Apartment Staffing (PAS) Please check the following box to agree to the Background Investigation for Employment by Platinum Apartment Staffing (PAS) * I agree
I hereby authorize and give my consent for PAS to conduct a background check, in connection with my potential employment with the company. I am herby advised the PAS background check will involve contacting some or all of the following organizations: federal and state law and drug enforcement agencies, department of motor vehicles, as well as other government agencies that retain criminal history records. I authorize PAS to contact these organizations to obtain information concerning me. I may submit a written request to PAS within 7 days to obtain detailed information about the scope of their investigation.
I hereby authorize the above listed organizations to release any criminal history records pertaining to me to PAS officials. I understand that a record of criminal conviction does not automatically disqualify an applicant from being employed by PAS. PAS officers, agents and employees are hereby released of any and all liability as a result of the use or disclosure of any information received during the described background investigation. PAS may at its sole discretion, deny me employment based upon only information receive from my background investigation, which PAS considers unsatisfactory. I have read and understand the terms of authorizing the background check described above. I further understand the information requested below will be used to conduct a background check. Signature *
Typing Name will be considered electronic signature.
SSN# DOB Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 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 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 DL # Employment Verification Employee Name Employer: Eligible for Re-hire Dates of Employment Additional Comments W-4 Employee's Withholding Allowance Certificate
Complete For W-4 so that your employer can withhold the correct feder income tax from your pay. Give Form W-4 to yoru employer. Your Witholding is subject to review by the IRS
First Middle Last Social Security Number Home Address (number and street or rural route): * Filing Status: *
Note. If married, but legally separated, or spouse is a nonresident alien, check the "Single" box.
Step 2: Multiple Jobs or Spouse Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income eraned from all these jobs.
only one of the following. TIP: To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator. Complete steps 3-4(b) on Form W-4 for only ONE of thse jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete steps 3-4(b) on the FOrm 2-r for the highest paying job) Step 3 Claim Dependents
If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000 * Multiply the number of other depedents by $500 * Add the amounts above and enter the total here * Step 4 (optional): Other Adjustments (a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of the other income here. This may included interest, dividends, and retirement income (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here. Extra withholding. Enter any additional tax you want withheld each pay period Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete. *
Employee's Signature (This form is not valid unless you sign it.)
MM slash DD slash YYYY Form I-9 Employment Eligibility Verification
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
First Middle Last Maiden Name Date of Birth Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 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 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Social Security # Address I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following): Alien # Or Admission # Authorized to work until (expiration date) Employee's Signature Date
MM slash DD slash YYYY Preparer and / or Translator Certifcation Preparer and/or Translator Certification (check one)
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Yes Preparer's / Translator's Signature Date
MM slash DD slash YYYY Preparer's / Translator's Name
First Last Preparer's / Translator's Address Section 2. Employer Review and Verification
(To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed below on LIST OF ACCEPTABLE DOCUMENTS, and record the title, number, and expiration date, if any, of the document(s).)
Are you using List A, or List B and List C? *
Please select if you are using 1 item from List A, or an Item from List B and an item from List C
Document Title Issuing Authority Document # Expiration Date (If any) Upload File Document Title Issuing Authority Document # Expiration Date (If any) Upload File I attest under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) _________________ and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.) I agree Date employee began employment
MM slash DD slash YYYY Employee or Authorized Representative Signature Title Date
MM slash DD slash YYYY Business or Organization Name Employers Business or Organization Address Reverification and Rehires
(To be completed and signed by employer or authorized representative.)
First Middle Last Date of Rehire
MM slash DD slash YYYY If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. I attest under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. I agree Signature of Employer or Authorized Representative Date
MM slash DD slash YYYY Direct Deposit Information Account type Account Number ABA Routing Number Name
This field is for validation purposes and should be left unchanged.