Date of application:

Position applied for: Please Make A Selection Cleaning Technician Team Leader Trainer QA Manager Sales Estimator Office Manager Operations Manager

First Name: Last Name:

Email:

How did you learn about us: Please Make A Selection Internet Search Friend Referred Me Vehicle Signs Snag A Job Online Gloucester County Times Trend Craigs List Yellow Pages Other

Address:

City:    State:   Zip Code:

How long at this address?

My telephone is: ( ) - -

Prior address:
                              (If less than 3 years)

What hours are you available to work on the following week days?
  Mon    Tues    Weds   Thurs   Fri

Are you available to work: Make A Selection Full Time Part Time Temporary

If you are hired, when can you start work?

Driving is a requirement of the job. 
  Can you travel if a job requires it?  YES    NO

Do you have a valid New Jersey Drivers License?  YES    NO  
  State

Do you have full time access to a vehicle?  YES    NO

Is your vehicle in good and safe mechanical condition? YES    NO

Is the Vehicle covered by comprehensive liability insurance?  YES    NO
  Make of Vehicle   Model   Year

Are you able, at time of employment, to submit verification of your legal
  right to work in the U. S.?*     YES    NO
      *Verification and completion of the I-9 form must be submitted no later than
        3 business days after hire.

Are you able to perform typical taskes associated with cleaning duties;
  (stand for extended periods of time, reach, push, pull, stretch, bend, stoop, kneel and lift up to 50 pounds?    YES    NO

Are you presently employed?   YES    NO
  If yes, may we contact your current employer?    YES    NO

Have you ever filed an application with us before?  YES    NO
  If yes, please give date;

Have you ever been employed with us before?    YES    NO
  If yes, please give date;

Which of the following categories of jobs have you had?
        Housecleaning          Hotel/Motel          Restuarant
        Fast Food                Janitorial             Sales
        Clerical                   Homemaker            Manufacturing
        Secreterial              Service                 Other (explain)
        
        If other please explain here;
       

SPECIALIZED SKILLS
  If you are applying for a clerical, secretarial, office manager, sales, estimator
  position place a check mark next to each skill you are proficient in;
     Multi-line Telephone System Computer  Laptop  Ink-Jet Printer
     Laser Printer Copy Machine Scanner Calculator
     Networking  Internet Fax  EMAIL
    Windows Software MS Word MS Excel MS Powerpoint
     MS Outlook MS Access Quickbooks Service CEO
      Dreamweaver  Publisher Acrobat Photoshop  Illustrator

Have you been convicted of a criminal offence? YES    NO
  Have you ever been bonded?  YES    NO  
  Has your driver's license ever been suspended?  YES    NO
  All employees are required to be bonded, and we will conduct a criminal background
  check and driving record check prior to hiring any candidate,

WORK EXPERIENCE:  List below your last three employers, starting with your present
  or last place of employment.  You may include in such history any verified work performed
  on a volunteer basis.

Please include beginning and ending dates of employment, name and address of employer,
   supervisors name and telephone number, salary, position held and reason for leaving;  

Please include beginning and ending dates of employment, name and address of employer,
   supervisors name and telephone number, salary, position held and reason for leaving;

Please include beginning and ending dates of employment, name and address of employer,
   supervisors name and telephone number, salary, position held and reason for leaving;      

EDUCATION:  List below your educational background.

Please include dates of attendance, name and location of school, highest
  grade completed and major area fo study;  High School
   

Please include dates of attendance, name and location of school, highest
  grade completed and major area fo study; College
   

Please include dates of attendance, name and location of school, highest
  grade completed and major area fo study; Other
    

PERSONAL REFERENCES:  List the names of three persons not related to you,
  whom you have known for at least three years.

Please include name, address, telephone number, occupation and years known;
   

Please include name, address, telephone number, occupation and years known;
   

Please include name, address, telephone number, occupation and years known;
   

TO WHAT EXTENT WOULD THE FOLLOWING JOB CHARACTERISTICS
  BE ATTRACTIVE TO YOU?

More flexible daytime hours than other jobs;
     Very Great  Great   Somewhat   Little   Very Little

Working in a team environment;
     Very Great  Great   Somewhat   Little   Very Little

The opportunity to become a team manager;
     Very Great  Great   Somewhat   Little   Very Little

Physical activity and exercise;
     Very Great  Great   Somewhat   Little   Very Little

The opportunity to work full-time part-time;
     Very Great  Great   Somewhat   Little   Very Little

Helping clients by keeping their homes clean;
      Very Great  Great   Somewhat   Little   Very Little

A good relationship with fellow employees;
      Very Great  Great   Somewhat   Little   Very Little

Recognition from management for good work;
      Very Great  Great   Somewhat   Little   Very Little

The opportunity to earn bonuses and awards;
     Very Great  Great   Somewhat   Little   Very Little

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING
  THIS APPLICATION.  ONLY THOSE APPLICATIONS WHICH ARE SIGNED AND
  DATED ARE CONSIDERED VALID.  IF YOU HAVE ANY QUESTIONS REGARDING
  THIS STATEMENT, PLEASE CALL OUR OFFICE AND ARRANGE TO COME IN AND
  FILL OUT AN APPLICATION SO THAT YOU CAN HAVE YOUR QUESTIONS
  ANSWERED BEFORE SIGNING.

APPLICANT'S STATEMENT;

In signing this application, I certify that all of the foregoing information is a complete and accurate statement of the facts and understand that if any misrepresentation, omission or falsification be discovered, it will constitute grounds for dismissal.  I hereby authorize the company, to which I am applying, to conduct any investigation necessary concerning any part of my background related to the position I am seeking, including, but not limited to, the obtaining of a polic report and driving record.  I authorize any of the persons or organizations named in this application to provide complete information and records regarding my employment, education, character and qualifications.  I release all parties from any liability in connection with the provision and use of such information.

                                                                           YES    NO

I understand and agree that, if employed by this company, I will be responsible for familiarizing myself with the rules and regulations of the company as they presently exist or are later modified and that I will abide by its rules and regulations which I understand are subject to change.

                                                                         YES    NO

I also understand that no representative of the company has any authority to enter into any employment agreement for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment.  I further understand that, if hired, my employment is for no definite period of time and may be terminiated by either party at any time.

                                                                       YES    NO

I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the employer may discharge employee at anyt ime with or without cause.  It is further understood that nothing said or written now or in the future is to be interpreted to the contrary. No officer, supervisor, employee or representative of Dial-A-Mop, LLC has authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.

                                                                    YES    NO

I have read, understand and agree with the above.  By clicking on the "SEND" buttom below I further understand and agree that I have electronically signed this application and validate it authenticity.