All fields labeled with an asterisk (*) are required.
Personal Information
*Full Name:
*Address:
*City:
*State:
*Zip:
*Daytime Phone:
Evening Phone:
*E-mail:

List States and Counties of Residence for the Past Seven Years:
*Are you a Citizen of the U.S. or do you have the legal right to work in the U.S.?

Yes No

(Any offer of employment is conditioned upon completing form I-9 and providing documents establishing identity and work authorization)
*Have you ever been convicted of a crime other than a minor traffic violation?

Yes No

If yes, please explain offense and final disposition:


(The existence of a criminal record will not automatically disqualify
you from employment.)
*Have you previously applied for employment with Clean Image Custodial?

Yes No

If yes, when?
*Are you related to any employee of Clean Image Custodial?

Yes No

If yes, please indicate name and relationship of Clean Image Custodial employee:
*Are you eighteen years of age or older?

Yes No
Education History
High School: Name:
Address:
  Did you graduate? Yes No
College: Name:
Address:
Dates Attended: From: To:
  Did you graduate? Yes No
Graduate School: Name:
Address:
Dates Attended: From: To:
  Did you graduate? Yes No
Are you presently enrolled in school? Yes No

If yes: Daytime Evening

Where are you enrolled?
Military Service History
Military Service Status:
Branch of Services:
Dates of Service: From: To:
Employment History
List all present and past employment for the past ten years, beginning with the most recent.

1.		 Company Name:
Address:
Phone:
Final Wage or Salary:
Dates Employed: From: To:
Job Title:
Reason for Leaving:
Immediate Supervisor:
Duties:

2.		 Company Name:
Address:
Phone:
Final Wage or Salary:
Dates Employed: From: To:
Job Title:
Reason for Leaving:
Immediate Supervisor:
Duties:

3.		 Company Name:
Address:
Phone:
Final Wage or Salary:
Dates Employed: From: To:
Job Title:
Reason for Leaving:
Immediate Supervisor:
Duties:
References
List (3) persons, not related, who have known you for two (2) years or more and whom we may contact.

1.		 Name:
Address:
Occupation:
Telephone:

2.		 Name:
Address:
Occupation:
Telephone:

3.		 Name:
Address:
Occupation:
Telephone:
Other Accomplishments
Please list below any other job related accomplishments, professional distinctions, or volunteer work.
Work Availablity
*Position Applying For:
  
*Date Available:
*Salary Expected:
*Status: Full Time Part Time On-Call
Agreement
Please read carefully.

1. I certify that the answers given herein are true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, with the exception of contacting my present employer if I have so requested on page two.

2. I understand that my continued employment will depend upon the successful completion of work assigned to me during a new hire period of up to ninety (90) days and upon my continued successful performance.

3. While this application is on file for a period of one year (as required by law), I acknowledge that this application will be considered active for a period of sixty (60) days. At that time, I must submit a new application to be considered for any employment openings.

4. I understand and acknowledge that unless otherwise defined by applicable law or written agreement with Clean Image Custodial, any employment relationship with the Company is considered "employment at will", which means the employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by any contract or written agreement initiated by the President/CEO of Clean Image Custodial.

5. If Clean Image Custodial should employ me, I understand that any false, incomplete, or misleading information given on this application or during an interview shall result in immediate discharge.

6. I authorize an inquiry into my background by all persons, schools, companies, corporations, credit bureaus, law enforcement agencies, doctors and other consumer reporting agencies to supply information concerning my previous employment, education, credit, driving record, etc.

7. I authorize the references and previous employers listed above to give representatives of Clean Image Custodial any and all information concerning my previous or current employment and any pertinent information they may have, personal or otherwise, and release all parties from any and all liability from any damage that may result.

By clicking the "Submit" button below, I certify that I have read, understand and agree to the above statements.



All fields labeled with an asterisk (*) are required.

Clean Image Custodial is an Equal Opportunity Employer. Clean Image Custodial does not discriminate in employment and no question on this application is used for the purpose of limiting any applicant's consideration for employment on a basis prohibited by local, state or federal law.
 
 
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