Position Applied For:
Today's Date
How did you hear about us?		Advertisement Relative Walk-In Other Employment Agency Friend
First Name
Last Name
Street Address 1
Street Address 2
City
State		Kentucky Indiana Ohio Michigan Pennsylvania West Virginia
Home Phone
Cell Phone
Email Address
If you are under 18, can you provide required proof of eligibility to work?		Yes No
Have you been employed with us before?		Yes No
Are you currently employed		Yes No
May we contact your present employed?		Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status?		Yes No
Amount of time you are able to work		Full Time Part Time Temporary
Are you currently on lay-off status?		Yes No
Do you have dependable means of transportation to and from work?		Yes No
Have you been convicted of a felony in the last 7 years? (Conviction will not necessarily disqualify employment)		Yes No
If yes, please explain:
Education: Name & Address of School Course Of Study Years Completed Diploma Or Degree High School: College: Degree: Other (specify)
Additional Information: State any additional information you feel may be helpful to us in considering your application. Summarize skills or other experience.
DO NOT ANSWER THESE NEXT TWO QUESTIONS UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING
Are you capable of performing in a reasonable manner the activities involved in the job or application for which you have applied?		Yes
A description of the activities involved in such a job or occupation is available from employer.		Yes No
EMPLOYMENT EXPERIENCE
Start with your present or last job. Include any job-related military assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
Date Employed From/To Work Performed Employer   Address    Telephone Job Title    Supervisor  Reason For Leaving   Rate Of Pay
Date Employed From/To Work Performed Employer   Address    Telephone Job Title    Supervisor  Reason For Leaving   Rate Of Pay
Date Employed From/To Work Performed Employer   Address    Telephone Job Title    Supervisor  Reason For Leaving   Rate Of Pay
References Name Address Phone 1. 2. 3.
INSURABILITY CONSENT AGREEMENT
Consumer reports may be obtained as part of the Mark's Cleaning Service Inc. evaluation of my job application/employment. The reports may be procured by Lance & Co. Insurance Agnecy, LLC and my include my driving record, as assesment of my insurability under the Company's insurance coverages or other consumer reports. By submitting this form, I hereby authorize the Company to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes. Name of Job Applicant Driver's License Number Date Of Birth
CRIMINAL RECORD REVIEW
I understand that my work for the Company requires the Company to review my criminal record to determine if I have been convicted of a crime (including a traffic offense) and, if so, the nature of the crime. You must check one of the boxes below:
I am disclosing that I have been convicted of the following crimes: I have no convictions to disclose
Crime Date Of Conviction Where Conviction Occurred Felony/Misdemeanor
A conviction does not mean that you will not be considered for employment. The Company, however, reserves the right to use the information for legitimate business purposes, including deciding whether to make an offer of employment and, if employment is offered, whether you qualify to perfrom available work. For any conviction listed above, please provide any information you believe should be considered by the Company in deciding whether you are qualified to perform the position that you seek.
By checking this box, I understand that if I falsify the the information provided above or if I omit any requested information, that if and when such conduct is discovered, I will be terminated from employment with the Company based upon such conduct. If after I begin employment, I am disqualified from working at a particular site based upon information obtained by a third party (for example, FBI), I will be terminated from employment with the Company.
REFERENCE AND POLICE RECORD AUTHORIZATION
I understand that based upon my application for employment, the Company, its officers, agents, representatives, or its authorized employees may request each former company and each person, firm or entity which I have given as a reference to furnish any information concerning me and my prior work, my habits, character and/or skills. I authorize such information requests. Further, I hereby waive any privilege relating to such information and release the Company and any reference source from any liability arising out of or relating to such information and release the Company and any reference source from any liability arising out of or relating to furnishing such information to the Company. I also authorize the Company to make any lawful examination of my criminal record. I release the Company and any police or law enforcement agency, and any individual connected therewith, from any liability arising out of or relating to the requested criminal record information. By checking this box,  I agree with the above statements.
CLICK ON THE 'SUBMIT' BUTTON TO SUBMIT YOUR APPLICATION