APPLICATION FOR EMPLOYMENT Employee Information Name * First Name Last Name Other Names Used (if any) First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country US Social Security Number (SSN) * Date of Birth * MM DD YYYY Contact Information Email Address * Phone * (###) ### #### Can also be reached at (###) ### #### Background Are you over 18? * Yes No Do you have a car? * Yes No Date available for work? * MM DD YYYY Salary Requirements * Floor care experience? * Yes No Machines you can operate? * Vacuum Buffer Steam Extractor Have you ever supervised a crew? * Yes No If yes, how many? 1 2-4 5+ Do you have any physical disabilities that would impair your work production? * Yes No If yes, please explain. Have you ever been injured at work? * Yes No If yes, please explain. Previous Employment Data Name of Company Phone Number (###) ### #### Name of Supervisor Job duties Name of Company Phone Number (###) ### #### Name of Supervisor Job Duties Thank you!