Employment Application

General Information

Referral Source (Please check the appropriate category and name the source.)

If not, your employment will be subject to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have to obtain a work permit.
What is your desired salary range or hourly rate of pay?

Employment History

Starting with your most recent employer, provide the following information

Skills and Qualifications


Military Service


Provide names and telephone numbers of three business/work references who are not related to you and are not previous supervisors as that information was provided in your Employment History. If you do not have three business references, please list three school or personal references who are not related to you.

Related Information

Applicant Statement

I hereby certify that the facts set forth in the above Application for Employment are true and complete to the best of my knowledge. I understand that, if employed, I will be required to provide evidence of my right to work in this country. I understand that, if employed, falsified statements on this Application shall result in my dismissal. I understand also, that if employed, I am required to abide by all of the rules and regulations of the Company. I hereby authorize QCSS Smartcenter to make any investigation of my personal and occupational history. This Application is not a Contract of Employment and does not supply any of the terms of a Contract of Employment. If employed, I understand that my employment is at-will and can be terminated, with or without notice, and with or without cause at any time at the option of either the Company or myself.

Any offer of employment I may receive from QCSS Smartcenter is contingent upon my successful completion of the Company’s pre-employment screening process. I expressly authorize without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and education institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of QCSS Smartcenter.


I understand that I have fully read, understand and accept all terms of the foregoing Applicant Statement.

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