The Client (Dentist) is your employer and responsible to
pay you according to labor laws. Dental Statewide Staffing Inc. is a referral
service, not your employer. Client pays you & each office has different pay
periods for each office. Carry DL & SS card. If this is a concern ask when
confirming. No Fees are charged to you
1. You will call each office the day we give you the
position & the day before to confirm hours and directions.
2. If office asked
for your phone # for temporary position, let the office know that you don’t
give phone number out. If they need to get in touch with you have them call DSS
inc office for any cancellation or changes.
3. You will not barter with office for future days
without fees to DSS.
jobs are confidential and no referral of friends or family when placed in
offices by DSS inc service.
Don’t ask or receive any doctor or staff referrals to other jobs when sent to
6. When you were sent to a
position through DSS and you later answered one of the Clients Ads or faxing
resume, or they call you for a temp or long-term position. The Dentist and YOU
are still responsible under contract of our office for one year from the last
date of service to call us of any extra days or changes.
7. If Client asks you to work additional days that are not scheduled through us. You are responsible to inform us immediately. Even if
Client tells you they will call you need to confirm this with us also.
8.During a Temp position, you will be paid for the hours worked. We
cannot guarantee that offices will not cancel day or afternoon.
You declare that all licenses and current documents are
true from the State of California.
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
[Goodwill Industries of North Florida (Goodwill)] is a Federal contractor and an Equal Opportunity Employer. Goodwill is subject
to Executive Order 11246, which requires government contractors to take affirmative action to ensure that equal opportunity is provided
in all aspects of their employment. In addition, we are subject to Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as
amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative
action to employ and advance in employment protected veterans. In order to comply with these laws, Goodwill invites applicants to
voluntarily self-identify their gender, race/ethnicity and protected veteran status. Goodwill does not discriminate on the basis of race,
religion, color, sex, sexual orientation, gender identity, age, protected veteran status, non-disqualifying physical or mental disability,
national origin, genetic information, or any other basis covered by appropriate law. All employment is decided on the basis of
qualifications, merit, and business need.
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information
obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and
regulations, including those that require the information to be summarized and reported to the federal government for civil rights
enforcement. When reported, data will not identify any specific individual.
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of
reasonable accommodation include making a change to the application process or work procedures, providing
documents in an alternate format, using a sign language interpreter, or using specialized equipment.
, confirm that I am available for temporary assignments which may be offered to me in accordance with condition applicable to Goodwill Staffing Services, as set out below.
1. Wages will be paid only for those hours which are actually worked, lunch hours excluded. Goodwill Staffing Services pays its employees once a week. Our pay period starts on Sunday and ends on Saturday. Payday is every Friday from 8:00 a.m. to 3:00 p.m. All checks that are not picked up on Fridays will be mailed via the US Postal Service. If you cash your check before the date on the check issued to you there will be a $50 early cashing penalty fee.
If a check is lost or stolen it must be reported immediately. Checks will be reissued two (2) weeks after the stop payment has been placed on the check unless it has been cashed prior to the stop payment. I understand in order to be paid in a timely matter; time cards must be turned in no later than 9:00 A.M. each Monday following the week worked. Any late time cards will not be paid until the next payroll period which is the following week.
2. I understand I am an employee of Goodwill Staffing Services, and I represent Goodwill Staffing Services when sent out on a temporary assignment. I understand that I am expected to complete any job assignment that I accept. Should an offer of employment be made by a Client/Company/Employer while the employee is on an assignment of Goodwill Staffing Services, the employee is free to accept such an offer, however, the employee is required to advise Goodwill Staffing Services of such an offer and acceptance.
3. If for some unexpected reason, such as an emergency or illness, I can not make it to work or will be late, I will contact Goodwill Staffing Services at least one hour prior to my scheduled shift so Goodwill Staffing Services can call the Client/Company/Employer and/or find a replacement. All absences 3 days and over must be supported with documentation (i.e. from a doctor).
4. If I sustain an injury on the job, I will inform the Client/Company/Employer and Goodwill Staffing Services immediately after the accident. Goodwill Staffing Services will coordinate with the client and myself, the proper procedure for treatment and reporting of the accident.
5. Confidentiality of information obtained on an assignment is paramount. I agree that I will not divulge, to any person, information obtained on as assignment that may represent a breach of trust, security, or trade secret that would be injurious to the client of Goodwill Staffing Services.
6. I understand that Goodwill Staffing Services has a Drug & Alcohol Policy. I understand that a pre-placement drug test will be conducted for applicants under consideration for certain assignments. No drug and/or alcohol test will be conducted without an employee's consent. However refusal to consent will result in disciplinary action up to and including termination.
7. There may be assignments offered from time to time which may require passing a physical examination. I am free to reject such examination and in such a case that particular assignment may be held open for me or I may be withdrawn from it. Other assignments may still be offered to me which don't require a physical.
8. I understand that Goodwill Staffing Services requires two weeks notice of my intention to resign. If you plan to voluntarily terminate your employment in good standing, you must provide two weeks notice. Notice of intention to resign must be given in writing to Goodwill Staffing Services.
9. I understand that Goodwill Staffing Services, Goodwill Industries of the Chesapeake, Inc., and Goodwill Works, have established performance standards for all employees. Employees may be terminated for attendance infractions, incompetence, irresponsibility, insubordination, and/or failure to observe rules, policies, and regulations. Please note that these are not the only reasons an employee may be terminated. Fighting, theft, or insubordination are grounds for immediate termination. I also understand that failure to call and advise Goodwill Staffing Services of any absence is considered a no call, no show, which is job abandonment and grounds for immediate termination.
10. I understand that all assignments through Goodwill Staffing Services are temporary work assignments. All job placements are based on an employer's temporary employment needs and therefore can end at any time and for any reason or cause.
PLEASE INITIAL HERE:
11. I have read and fully understand the above statements regarding Goodwill Staffing Services employee agreement and agree to the same. I understand that failure to comply with this agreement could lead to my termination.
12. I, the undersigned, acknowledge receipt of a copy of this employee agreement to keep.
The Alcohol and Drug Free Workplace Program of Goodwill Staffing Services was established to maintain a productive, secure, safe, and healthy environment for all employees. Through this program, Goodwill Staffing Services intends to:
This program will apply to all applicants for employment and Goodwill Staffing Services employees.
Employees will be tested for the use of drugs and/or alcohol under the following conditions:
Employees will be paid for the time needed to comply with testing when required by Goodwill Staffing Services Applicants for employment will not be compensated for the time needed to comply with testing. Urine specimens will be tested for the presence of drugs. Alcohol testing will be performed using an evidential breath testing device. Goodwill Staffing Services reserves the right to require blood alcohol testing for reasonable suspicion and post accident. All drug and alcohol testing will be carried out in compliance with Maryland law. Specimens will be tested by a NIDA certified laboratory.
Any employee who alters or attempts to alter, substitute or contaminate a drug and/or alcohol specimen will be subject to disciplinary action up to and including termination.
2. Employees must notify Goodwill Staffing Services of any criminal drug or alcohol statute conviction within five (5) days of such conviction. Failure to do so may be considered misconduct and result in disciplinary action up to and including termination.
3. No prescription drugs will be brought onto company property by any employee other than the employee for whom it is prescribed. Medications must be carried in the prescription container. The use of prescription drugs will be according to the manner and quantity prescribed. Employees on physician prescribed medicine must notify their supervisor if there is a possibility the medication could affect job performance. Goodwill Staffing Services may refuse to allow the employee to work unless the employee stops taking the medicine: a) until the effects will not be experienced during the employee's working hours; or b) upon presenting a note from the prescribing physician stating there are no adverse side effects from taking the prescription which would impair the employee's ability to perform his/her job safely. Failure to do so will be considered misconduct and may result in disciplinary action up to and including termination.
4. No drug and/or alcohol test will be conducted without an employee's consent. However, refusal to consent will result in disciplinary action up to, and including, termination.
5. A tested employee will be informed of the name and address of the lab upon request, and may request independent testing at the employee's expense. Any employee who tests positive will be provided with a copy of the lab test results, a copy of this written policy, a written notice of disciplinary action, and Test results will be kept confidential and disclosed only on a need-to-know basis.
I, the undersigned, acknowledge receipt of a copy of this alcohol & drug free workplace program to keep.
I certify that the information I have provided on this application and any attachments thereto, is true and complete to best of my knowledge and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated.
I authorize Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. to investigate my professional background, educational background, qualifications and all other statements made on this application. I release Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. and anyone supplying information to Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. as well as their respective agents, from liability in connection with this investigation.
I understand that, as a condition of employment, I may be asked to disclose information pertaining to felony convictions, within the last seven (7) years. I understand that certain positions, as a condition of employment, require a criminal background investigation permitted under the Fair Credit Reporting Act. If I am applying for a position that requires such an investigation, I understand that any offer of employment made by Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. is expressly conditioned on the findings of the investigation. I understand that if Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. obtains information that leads it to conclude, in its discretion, that I should not be employed, it may rescind any job offer or terminate my employment.
I understand that, as a condition of employment, or at any time during the employment relationship, I may be asked to consent to a drug test. If I refuse to consent or cooperate in the conduct of such a test or if I test positive for a controlled substance, I understand that Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. may rescind any job offer or terminate my employment.
I further understand that if hired by Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. my employment is for no definite period and that either Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. or I may terminate the employment relationship without prior notice or reason. I also understand that none of Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc.'s practices and policies are to be construed as imposing any binding obligation on Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc.'s, and that they are subject to change or deletion at any time.
UNDER MARYLAND LAW, AM EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECTTO A FINE NOT EXCEEDING $100.00.
Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. is an equal opportunity employer dedicated to nondiscrimination in employment on the basis of race, color, religion, age, gender, disability, marital status, sexual orientation, genetic information, national origin, veteran's status or other classification covered by federal, state or local law.
I have read and understand the information outlined in these paragraphs and by providing my signature below I agree with these terms.
I agree with the above statement.
Goodwill Staffing Services takes your health and safety very seriously. Because it is important that we be able to manage our safety program, there are specific rules you must follow to prevent injuries. If you have an injury on the job you must immediately notify a Goodwill Staffing Services representative before obtaining medical treatment. Failure to follow the basic safety rules and instructions may result in disciplinary action, up to, and including termination.
1. If you have an injury:
2. Personal protective equipment (PPE) must be worn when required on specific jobs. You will be provided equipment designed specifically to protect you from injury. Any deficiencies in the required PPE must be immediately reported to your Goodwill Staffing Services representative.
3. Eye protection must be worn if you are exposed to flying objects and dust.
4. Report hazards immediately to a company official who has the authority to see that it is corrected.
5. Wear clothing that fits the job. Sandals, canvas or similar sport shoes are prohibited at production or construction sites, as are loose hair, clothing and jewelry when working around machinery.
6. If you work in a way that might cause an injury to yourself or others you will be warned and disciplinary action may follow, up to and including termination.
7. Do not work in any situation where the work might be considered dangerous. If there is doubt, consult your Goodwill Staffing Services representative.
8. No practical jokes, scuffling or other horseplay in permitted.
9. Do not operate a machine unless guards are in place and the machine is in good working order.
10. Keep your area clean. You are responsible for cleaning up any hazards you create.
11. Obey "no smoking" rules at each job site.
12. Obey all rules regarding use of personal cell phones at each job site.
13. You are strictly forbidden to ride on forklifts and carriers or any mobile equipment as passengers.
14. You must be checked out on trucks, forklifts and production equipment prior to use.
15. Do not walk in the pathway of operating equipment or vehicles, or walk across moving conveyors.
16. Do not use your hands or any portion of your body to reach between hazardous moving parts of a machine for any reason.
17. The use of intoxicating liquor or drugs on the job or reporting to work under the influence of intoxicants is prohibited.
18. No weapons are permitted in the workplace.
19. Get to know where emergency exits, fire extinguishers and safety equipment are located.
I have read and understand these safety rules. I understand I must obey all safety rules, regulations and safe work practices. Failure to obey safety rules and safe work practices, including accident reporting procedures, may be grounds for disciplinary action up to and including termination.
As an Equal Opportunity employer ,Goodwill Industries of the Chesapeake ,Inc. does not discriminate against qualified applicants based upon race ,color, religion, age, gender, disability ,marital status, sexual orientation , genetic information, national origin ,veteran’s status ,or such classification covered by federal, state or local laws.
We invite you to complete the self-identification fields below used for compliance with government regulations and record keeping guidelines .Completion of these question is voluntary, and this information is not available to hiring managers. Refusal to provide the requested information will not result in adverse treatment .Information provided is not considered part of your application and will be treated confidentially.
Thank you for your help and cooperation.
Goodwill Industries of the Chesapeake is an equal opportunity corporation and does not discriminate on the bases of race ,color, sex, national origin, religion, age, disability or veteran’s status in admission or access to, or treatment or employment in, its programs and activities. Individuals who may have inquiries regarding the corporation’s policy and procedures should contact Vice President of Human resources at 410-837-1800.
This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974,as amended by the jobs for Veterans Act of 2002,38 U.S.C. 4212 (VEVRAA),which requires Government contractors to take affirmative action to employ and advance in employment.
These classifications are defined as follows :
If you believe you belong to any of the categories of protected veterans listed above, please indicate by selecting the appropriate choice .As a government contractor subject to VEVRAA,
we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
Because we do business with government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing ,we are asking you to tell us if you have a disability or if you ever has a disability .Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job , any answer you give will be kept private and will not be used against you in any way.
If you already work for us , your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history of record of such an impairment or medical condition.
Disabilities include, but are not limited to:
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job .Examples of reasonable accommodation include making a change to the application process or work procedures ,providing documents in alternative format , using a sign language interpreter , or using specialized equipment.
i section 503 of the Rehabilitation Act of 1973, as amended .For more information about this form or the equal employment obligations of Federal Contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.This survey should take about 5 minutes to complete.