Employment Application

Electronic Signature

By typing your first and last name below and submitting this employment application form electronically, you acknowledge having read and understood our employment practices and policies as stated above.

Full Name*

First NameMiddle InitialLast Name

HomeBlis Is an Equal Opportunity Employer

Job Applied For

What type of employment are you seeking?*

Full-timePart-timeTemporary

When could you start work?*

MonthDayYear

Are you 18 years of age or older? *

YesNo

(If you are hired, you may be required to submit proof of age.)

Are You Legally Entitled To Work In The United States?

YesNo

Have you ever been convicted of any law violation? Include any plea of “guilty” or “no contest”? Exclude minor traffic violations*

YesNo

If yes, please give details. (A conviction will not necessarily disqualify an applicant for employment)

If employed, do you expect to be engaged in any additional business or employment outside of our job?*

YesNo

If yes, please give details.

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Day Time Phone*

Area CodePhone Number

E-mail

Do you have a valid driver's license?

YesNo

If Yes, State issued by:

License #

Expiration date

Employer's Name (Most current)

Position Held

Supervisor's Name

Telephone

Area CodePhone Number

Reason for Departure

Duties

Start Date

MonthDayYear

End Date

MonthDayYear

Start pay $

End pay $

May we contact this employer?

YESNO

If NO, reason why not

(2) Employer's Name

Position Held

Supervisor's Name

Telephone

Area CodePhone Number

Reason for Departure

Duties

Start Date

MonthDayYear

End Date

MonthDayYear

Start pay $

End Pay $

May we contact this employer?

YESNO

If NO, reason why not

(3) Employer's Name

Position Held

Supervisor's Name

Telephone

Area CodePhone Number

Reason for Departure

Duties

Start Date

MonthDayYear

End Date

MonthDayYear

Start Pay $

End Pay $

May we contact this employer?

YESNO

If NO, reason why not

List Other Cleaning Positions / Experience

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

High School or GED:

# of years completed

Diploma / Degree / Certificate

Address of High School (or institution awarding GED)

College or University

2nd Reference

# of years completed

Diploma / Degree / Certificate

Subjects Studied

Address of College or University

Vocational or Technical School

# of years completed

Diploma / Degree / Certificate

Subjects Studied

Address of Vocational or Technical School

Have you worked or attended school under any other names? *

YesNo

If Yes, give name(s) you used

Are you presently employed? *

YesNo

If Yes, whom do you suggest we contact?

Have you ever been fired from a job or asked to resign? *

YesNo

If Yes, please explain:

Give three references, not relatives or former employers

Name*

Address*

Phone*

Name

Address*

Phone*

Name*

Address*

Phone*

AFFIDAVIT, CONSENT AND RELEASE

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post employment drug screen as a condition of employment, if required.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature (typing my name below) consent to these statements.

Today's Date*

MonthDayYear

Type Signature*

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HomeBlis Application for Employment

APPLICATION FOR EMPLOYMENT

WORK HISTORY / EXPERIENCE

Special Skills

Education

References