Unique Employment

			Saturday, July 31st, 2010

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Unique PEO New Hire Form (Texas)

Personal Information

First Name	Middle Initial	Last Name

	Street and Number	City	State	Zip
Present Address

	Years	Months
How long have you lived there?

	Street and Number	City	State	Zip
Previous Address

	Years	Months
How long did you live there?

Telphone
No.

() -

Social
Security No.

Date of Birth

Sex

Male Female

Marital Status

Married Single

Exemptions Claimed On W-4

Position Desired

Part time Full time

Have you ever worked for this Company before?		Yes No
If Yes, please give date(s) and positions:

Have you ever pled guilty, or no contest to, or been convicted of any misdemeanor or felony?		Yes No
If Yes, please give the date(s) and details:

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial?	Yes No
If Yes, please give the date(s) and details:

NOTE:		(Do not include minor traffic citations and arrests or convictions which have been sealed or expunged.)

Record of Previous Employment

Present or Most Recent Employer

Address

Address2

City, State, Zip Code

Telephone

() -

EMPLOYED	PAY
From
(mo/yr)	Start
/	$.
To (mo/yr)	Final
/	$.

Your title and position	Name and Title of last supervisor

Exact Reason for Leaving

Previous Employer

Address

Address2

City, State, Zip Code

Telephone

() -

EMPLOYED	PAY
From
(mo/yr)	Start
/	$.
To (mo/yr)	Final
/	$.

Your title and position	Name and Title of last supervisor

Exact Reason for Leaving

Previous Employer

Address

Address2

City, State, Zip Code

Telephone

() -

EMPLOYED	PAY
From
(mo/yr)	Start
/	$.
To (mo/yr)	Final
/	$.

Your title and position	Name and Title of last supervisor

Exact Reason for Leaving

Employment Gaps:

Are you capable of performing the essential job duties of the position you are being hired for with or without reasonable accommodation?
Yes No

What accommodations if any would be necessary?

Have you ever been terminated or asked to resign from any job?		Yes No
If Yes, please explain circumstances:

May we contact your current employer?		Yes No
If No, please explain:

Please indicate any actual experience, special training and qualifications that you have which you feel are relevant to the position for which you are applying.

Have you ever used another name?
Yes No

Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record?		Yes No
If Yes, please explain:

If hired, can you furnish proof that you are over 18 years of age?
Yes No

Are you capable of satisfactorily performing the essential job duties required of the position for which you are applying?
Yes No

Do you have adequate transportation to and from work?
Yes No

How many days of work have you missed in the last three years due to reasons other than paid holidays and vacation?

Year Number of days

Year Number of days

Year Number of days

Education

Elementary:
Years Completed	4 5 6 7 8
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

High School:
Years Completed	9 10 11 12
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

College / University:
Years Completed	1 2 3 4
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

Graduate / Professional:
Years Completed	1 2 3 4
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

Trade or Correspondence:
Years Completed
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

Other:
Years Completed
Diploma/Degree
Describe course of study or major
Describe specialized training, experience, skills and extra-curricular activities

Personal References (Not previous employers or relatives)

Name
Occupation
Address
Street
City/State
Telephone Number
Number of years known

Name
Occupation
Address
Street
City/State
Telephone Number
Number of years known

Name
Occupation
Address
Street
City/State
Telephone Number
Number of years known

I CERTIFY THAT ALL THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND ACCURATE.
Yes No

Your digital signature. Please type your full name below.

Date:
Today's date is July 31st, 2010

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