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APPLICATION FOR EMPLOYMENT
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We are committed to a policy of Equal Employment Opportunity and will not discriminate on any legally recognized basis, invcluding, but not limited to, rage, age, color, religion, sex, marital status, national origin, citizenship, ancestry, physical or mental disability, vetern status, or any other legally protected basis.
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Last Name, First Name, Middle Initial
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Current Mailing Address
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Telephone Number
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Emergency Contact and Phone Number
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Driving is a requirement of the job. Is your license valid?
Yes
No
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Do you have full time access to a vehicle?
Yes
No
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Is your vehicle in good working condition?
Yes
No
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Is your vehicle covered by comprehensive liability insurance?
Yes
No
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Are you able, at the time of employment, to submit verification of your legal right to work in the U.S.?* *verification and completion of I-9 form must be submitted no later than 3 business days after hire.*
Yes
No
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Are you able to lift 50lbs. or more?
Yes
No
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Would you have difficulty standing, bending, or kneeling in connection with performing necessary cleaning duties?
Yes
No
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What days are you available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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What hours are you available to work on each of those days?
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If hired, when can you start work?
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Which of the following categories of jobs have you had?
House Cleaning
Fast Food
Homemaker
Hotel/Motel
Janitorial
Manufacturing
Restaurant
Sales
Service
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Other jobs not listed
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WORK EXPERIENCE
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List below your last three employers, starting with your present or last place of employment. You may include in such history any verified work performed on a volunteer basis.
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From
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To
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Name and Address of Employer #1
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Salary and Position
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Reason for leaving
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Supervisor's Name
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Name and Address of Employer #2
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Salary and Position
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Reason for leaving
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Supervisor's Name
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Name and Address of Employer #3
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Salary and Position
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Reason for leaving
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Supervisor's Name
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Educational Background- Name and Location of School- Area of Study
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Have you ever been convicted of a criminal offense?
Yes
No
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Have you ever been bonded?
Yes
No
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Has your driver's license been suspended?
Yes
No
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If yes, please explain
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To what extent would the following job characteristics be attractive to you?
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More flexible daytime hours than other jobs
Very Great
Great
Somewhat
Little
Very Little
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Working in a team environment
Very Great
Great
Somewhat
Little
Very Little
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The opportunity to become Team Leader
Very Great
Great
Somewhat
Little
Very Little
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Physical activity and exercise
Very Great
Great
Somewhat
Little
Very Little
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Helping clients by keeping their home clean
Very Great
Great
Somewhat
Little
Very Little
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A good relationship with fellow employees
Very Great
Great
Somewhat
Little
Very Little
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Recognition for good work
Very Great
Great
Somewhat
Little
Very Little
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The money I can earn from this job
Very Great
Great
Somewhat
Little
Very Little
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How did you hear about this job?
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PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING THIS APPLICATION. ONLY THOSE APPLICATIONS WHICH ARE SIGNED AND DATED ARE CONSIDERED VALID. IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE ASK BEFORE SIGNING
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APPLICANT'S STATEMENT
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In signing this application, I certify that all the foregoing information is a complete and accurate statement of the facts and understand that if any misrepresentation, omission or falsification be discovered, it will constitute grounds for dismissal. I hereby authorize the company, to which I am applying, to conduct any investigation necessary concerning any part of my background related to the position I am seeking, including, but not limited to, the obtaining of a police report and driving record. I authorize any of the persons or organizations named in this application to provide complete information and records regarding my employment, education, character and qualifications. I release all parties from any liability in connection with the provision and use of such information
Yes
No
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I understand and agree that, if employed by this company, I will be responsible for familiarizing myself with all rules and regulations of the company as they presently exist or are later modified and that I will abide by its rules and regulations which I understand are subject to change.
Yes
No
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I also understand that no representative of the company has any authority to enter into any employment agreement for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment. I further understand tht, if hired, my employment is for no definate period of time and may be terminated by either party at any time.
Yes
No
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I have read, understand and agree with the above.- Please type you name
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Date of application being signed
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This application is current for only 60 days from the date above signed. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.
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