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*Date of Birth (MM-DD-YEAR): --
Date of Birth is being requested in order to obtain accurate retrieval of records. |
| *Social Security Number: -- |
| *Emergency Phone Number: -- |
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If driving is a requirement of the job for which you are applying, do you have a current valid driver's license?
Yes or No
Driver's License Number:
State:
If driving is a requirement of the job for which you are applying, continued employment is contingent on your maintaining a current driver's license. |
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Have you ever been convicted of a felony or a crime which is related to the functions or qualifications of the position for which you are applying?
Yes or No
A conviction record will not necessarily be a bar to employment. |
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| *Please List (2) Personal References |
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| Please check areas in which you have experience: |
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Janitorial-Carpet/Upholstery Cleaning |
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Operation of floor scrubbing/buffing machines |
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| Have you ever applied for employment with us? Yes or No |
| Shifts for which you are available: Full-time Part-time AM PM |
Does heat, standing on your feet or lifting cause you any difficulties?
Yes or No
(If Yes, please explain limitations)
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| Please list your last (3) employers, beginning with the most recent: |
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| *Supervisor Name: (Last, First) |
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Pre-Employment Inquiry Release
In connection with my application for employment (including contract for services) with you, I understand that investigative background inquiries are to be made on myself including, criminal, and driving reports. I understand that you will be requesting information from federal, state, and county who maintain records concerning my past activities relating to my driving and criminal record.
I authorize without reservation, any party or agency contacted by Jack's Maintenance Service, Inc., to furnish the above information.
Note: Submission of this form constitutes a signature and the signing of this form.
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