Dividend Staffing Services Application Form
How did you hear about us?
Newspaper Friends/Family TV/Radio Billboard Other
Do you have Transportation?
Yes No
Have you worked for other temporary services?
Yes No
Which Temp Service?
Have you Ever been convicted of a Felony or Received Deferred Adjudication in Lieu of Sentencing?
Yes No
Please Explain:

Last Name/Maiden Name:
First Name:
Middle Initial

Home Address:

City:
State: Zip:
Phone:
Cellular/Other Phone Number:
Birth Month/Day:
Hourly Rate Desired:
$ Per Hour
Work Assignments
Will you Work Temporary Jobs?
Yes No
Will you Work Direct Hire?
Yes No
Will you work Short Term Assignments?
Yes No
Days you can work:

M T W TH F SAT SUN

Times you can work:
Days Evenings Nights Any
Employer (Most Recent First)
Employer Name:
Employer Phone:
Dates Worked: <dd/mm/yy>
From: To:
Employer Name:
Employer Phone:
Dates Worked: <dd/mm/yy>
From: To:
Employer Name:
Employer Phone:
Dates Worked: <dd/mm/yy>
From: To:


2107 Kemp Blvd.
Wichita Falls, Texas 76309-4300
Voice: 940.723.0150
Fax: 940.766.1680

Copyright® 2005-2007 Dividend Staffing, Inc.