Name (required) Email (required) Phone Number Home Address City State Zip Code Desired Position Desired Salary (per hour) Are you currently employed? Yes No Date you can start Are you legally eligible to work in the United States? Yes No Are you willing to take a drug test? Yes No How many hours can you work per week? 0-10 11-20 21-30 31-40 40+ Please list any times or days you are not available: Do you have any physical or mental disabilities which may limit your ability to perform essential functions of this job or which would require any special accommodations? Yes No If you answered yes to the question above, please explain: WORK HISTORY 1. Employer's Name (most recent) Position Held Supervisor Name Phone Number Home Address City Duties Start Date End Date Reason for leaving May we contact this employer? Yes No 2. Employer's Name (most recent) Position Held Supervisor Name Phone Number Address City Duties Start Date End Date Reason for leaving May we contact this employer? Yes No 3. Employer's Name (most recent) Position Held Supervisor Name Phone Number Address City Duties Start Date End Date Reason for leaving May we contact this employer? Yes No False information will cause removal from our registry. I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if this company at any time learns of falsification or material omission in the information provided on this application form and related documents. All references are hereby authorized to release all information which they may have relevant to my employment with them. I hereby release Priceless Clean, its affiliates, successors, and assigns, and all references from any liability that might be claimed because of information provided by such references. I agree that I will follow all Priceless Clean policies, rules, and procedures. I understand that Priceless Clean reserves the right to add, change, and/or delete any policies, procedures, work rules, and/or benefits at any time. I agree to make myself available for random drug testing. I have never been convicted of a felony and I have no criminal charges pending against me. I acknowledge that Priceless Clean will run a background check prior to employment. The check box below acts as your signature. If you check this box that means you agree to the statement above. I AGREE
