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Last, First, Middle

Present Address:




Mailing Address: (if different)




Are you 18 years or older? Yes No

*Are you a US citizen? Yes No

Are you an alien authorized to work in the US? Yes No Not Applicable

Special Questions

Can you provide proof of US citizenship? Yes No

What languages do you:
Speak fluently?
Read fluently?
Write fluently?

Have you ever been convicted of a felony with in the last seven (7) years? Yes No Record

Have you convicted of a misdemeanor within the past five (5) years or have you completed a period of incarceration within the past five (5) years for any misdemeanor (other than a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace)? Yes No Record

If the answer to any of the above questions is 'Yes', please state whether you were convicted more than five years ago for any offense (other than a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace)? Yes No Record

An application for employment with a sealed record on file with the commissioner of probation may answer 'No Record' with respect to any inquiry herein relative to prior arrests, criminal court appearances or convictions. An applicant for employment with a sealed record on file with the commissioner of probation may answer 'No Record' to any inquiry herein relative to prior arrests or criminal court appearances. In addition, any applicant for employment may answer 'No Record' with respect any inquiry herein relative to prior arrests, criminal court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.

Employment Desired:


(mm/dd/yyyy)


(mm/dd/yyyy)

Full-time Part-time
Days Evenings Weekends

Previous Work Experience:

Manager
Site Supervisor
Cleaner

Floor Care & Cleaning Equipment Used:

Buffers
Burnishers
Carpet Equipment
Other

Former Employers:

PLEASE PROVIDE EMPLOYERS FOR THE PAST FIVE YEARS

Date Month & Year Name & Address Of Employer Position Reason For Leaving
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:

In case of emergency notify:



I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified information on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result in furnishing same to you. I understand and agree that, if hired, my employment is for a definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

I agree that all information here is correct and authorize the submission of this form:

This form is dated as the 7th February 2012. Your IP address has been logged as 38.107.179.214.