MM slash DD slash YYYY
Do you have a vehicle?
Have you worked for a temporary placement agency before?
What is your availability?

Please indicate the YEARS OF EXPERIENCE you have in the following jobs (If NONE leave it BLANK):

Medical Questionnaire (CONFIDENTIAL)

We request basic medical information to help us find a work position and environment suitable to your capacity, thus minimizing the risk of serious injury to yourself, your colleagues, and/or everyone else involved.
Do you have a Heart Condition?
Do you have Epilepsy?
Do you have a history of Back Problems?
Do you have Diabetes?
Do you have High Blood Pressure?
Have you ever had an Eye Injury?
Are you Bondable?
Have you ever had and Major Joint Injuries?
Have you ever had a Head Injury?
Do you have a Hearing Problem?
Have you had any Previous Fractures?
Do you have any Allergies?*
Do you have a Hernia?
Do you have Dizzy Spells?
Are you currently taking any Medications?**
Are you Medically Cleared and Fit to Work with No Restrictions?

Please fill out an EMERGENCY CONTACT

(I authorize JPD Staffing Inc. to contact the following person(s) on my behalf in case of an emergency)

Dispatch Policy

I understand that if I wish to be eligible for dispatch work ("on-call" status) for a particular day, I will contact the JPD Staffing Inc. office and indicate my dispatch availability. If I cannot be contacted, I forfeit my "on-call" status position to the next available worker contracted. I understand that all work is on a casual basis and that I do not commence work until I have attended and started working at the location to which I have been dispatched. I also make clear my understanding that none of the above is a guarantee of work.

By submitting this form, I declare that all statements in this application are deemed accurate to the best of my knowledge. Any omission by myself or any misrepresentation is grounds for immediate dismissal. My employer can request an examination by a physician as required.

Get In Touch

Please fill out the contact form below to get in touch with us or call at 778 228 9181

    Back to top of page