*Empire Workforce Solutions: Application

Personal Information

Salutation:

*First Name:

M.I.:

*Last Name:

*Address:

*City:

*State:

*Zip Code:

Nickname:

Email:

*How did you hear about us?:

*Home Phone:

Cell Phone:

Other Phone:

Emergency Contact Information

Contact Name:

Contact Phone:

Check if you are legally authorized to work in the United States:

Resume: Your Resume will not be submitted unless you complete all *required fields

Resume File Name:

Position

*What position are you applying for:

Date available for work:

April 2025

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Minimum rate per hour:

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-to-hire:

Are you available direct-hire:

Cities Will Work:

Cities:

Previous Employment

Enter as much information as you can. More details will help us better serve you. (Salary/Pay per hour: NOT REQUIRED in AL, CA, CO, CT, DC, DE, HI, IL, MA, MD, ME, MN, NJ, NY, OR, VT, WA):

Employer Information 1

Name of Employer:

Employment Dates

From:

April 2025

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18	27	28	29	30	1	2	3
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To:

April 2025

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18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

Location

Address:

City:

State:

Zip Code:

Job Information

Supervisor Name:

Supervisor Phone:

Job/Position:

Pay Per Hour:

Reason For Leaving:

Employer Information 2

Name of Employer:

Employment Dates

From:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

To:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

Location

Address:

City:

State:

Zip Code:

Job Information

Supervisor Name:

Supervisor Phone:

Job/Position:

Pay Per Hour:

Reason For Leaving:

Employer Information 3

Name of Employer:

Employment Dates

From:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

To:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

Location

Address:

City:

State:

Zip Code:

Job Information

Supervisor Name:

Supervisor Phone:

Job/Position:

Pay Per Hour:

Reason For Leaving:

Employer Information 4

Name of Employer:

Employment Dates

From:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

To:

April 2025

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
14	30	31	1	2	3	4	5
15	6	7	8	9	10	11	12
16	13	14	15	16	17	18	19
17	20	21	22	23	24	25	26
18	27	28	29	30	1	2	3
19	4	5	6	7	8	9	10

Location

Address:

City:

State:

Zip Code:

Job Information

Supervisor Name:

Supervisor Phone:

Job/Position:

Pay Per Hour:

Reason For Leaving:

Temporary Employment

Check if you have ever used a recruiting firm to obtain employment (Temp or Perm):

Agency I

Firm Name:

Address:

City:

State:

Zip Code:

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:

Agency II

Firm Name:

Address:

City:

State:

Zip Code:

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:

Education

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

Name of college:

College degree:

College diploma/certificate:

Apply For The Job

Applying For The Job: The following information is provided to inform you about policies and disclosures that affect our Temporary Associates. Please review the disclosures and questions below, you are confirming your consent by checking the box to the bottom left.

By clicking the ‘Submit Your Application’ button below, you are confirming that you have read the disclosures contained herein and that they are true and accurate.

1. Voluntary Participation in E-Verify: Empire Workforce Solutions does not require employees to be E-Verified for employment purposes unless the employee resides in one of the following States: Alabama, Arizona, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, or Utah. However, from time to time, we place employees at companies that do require employees to be E-Verified. To provide employees the opportunity to work at companies that require employees to be E-Verified, Empire Workforce Solutions will send employee information to a Verification Center where the E-Verification process is completed. Participation in E-Verify is completely voluntary, and employment eligibility will not be affected if the employee does not wish to participate, unless the Employee resides in one of the States mentioned above.

2. Americans with Disabilities Act: Empire Workforce Solutions complies with the Americans with Disabilities Act (ADA) and will provide reasonable accommodations whenever possible and necessary to perform the essential functions of the job. Employees may be subject to medical examinations and skill & agility testing as required for employment purposes. Please check the box below, at the bottom, if you consent to such testing.
I authorize Empire Workforce Solutions to thoroughly investigate my references and to allow my former employer(s) to answer all questions and to provide all information in connection with this Employment Application. In addition, I consent and acknowledge that such shall act as a release of Empire Workforce Solutions, my former employer(s) and all other persons and companies from any and all claims or liabilities arising out of or in any way related to such investigation or disclosure.

I confirm and acknowledge that the information provided by me on this Employment Application is true and complete and I have not withheld any information that might adversely affect my opportunity for employment with Empire Workforce Solutions and I understand that it is grounds for immediate termination of employment if any information is found untrue, misleading or if I omit material facts.

Atlantic Solutions Group Inc., d/b/a Empire Workforce Solutions, and/or any affiliated entities (collectively, the “Company” or “we”) provide this California Privacy Notice (“Notice”) to describe our privacy practices with respect to our collection of Personal Information as required under the California Consumer Privacy Act of 2018 (“CCPA”). This Notice applies only to job applicants and candidates for employment who reside in the State of California (“Consumers”) and from whom we collect “Personal Information” as described in the CCPA. We provide you this Notice because under the CCPA, California residents who are job applicants qualify as Consumers. For purposes of this Notice, when we refer to Consumers, we mean you only to the extent you are job applicant of the Company who resides in California. We may collect Personal Information from you in a variety of different situations and using a variety of different methods, including, but not limited to, on our website, your mobile device, through email, in physical locations, through written applications, through the mail, and/or over the telephone. Generally, we may collect, receive, maintain, and use the following categories of Personal Information, depending on the particular Business Purpose and to the extent permitted under applicable law: Examples: Personal Identifiers & Contact Information - name, alias, postal or mailing address, email address, telephone number, social security number, driver’s license or state identification card number, passport number; Pre-Hire Information - Job application, resume, background check results, drug test results, job interview notes, and candidate evaluation records, Wage Opportunity Tax Credit (WOTC) information, Employment History - Information regarding prior job experience, positions held, names of prior supervisors, and when permitted by applicable law your salary history or expectations, Education Information - Information from resumes regarding educational history; transcripts or records of degrees and vocational certifications obtained. Personal information we collect, and our use of Personal Information may vary depending on the circumstances. This Notice is intended to provide an overall description of our collection and use of Personal Information. Generally, we may use or disclose Personal Information we collect from you or about you for one or more of the following purposes: To fulfill or meet the purpose for which you provided the information. For example, if you share your name and contact information to apply for a job with the Company, we will use that Personal Information in connection with your candidacy for employment. To comply with local, state, and federal law and regulations requiring employers to maintain certain records, as well as local, state, and federal law, regulations, ordinances, guidelines, and orders relating to COVID-19. To evaluate your job application and candidacy for employment. To obtain and verify background check and references. To communicate with you regarding your candidacy for employment. If you become employed by the Company, the Company will notify you of additional categories of Personal Information that it collects, receives, and maintains for business purposes.

Please CLICK 'SUBMIT YOUR APPLICATION' ONLY ONCE . Depending on your connection speed it may take a few seconds for your computer to cycle to the next screen. Please be patient, the system is processing the application. If you click this button more than once you run the risk of submitting multiple applications.