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Please list addresses for last 5 years:

How long at present address?

Social Security No.:

Position applying for (be specific):

Salary desired (be specific):

Days/ hours available to work:

How many hours can you work weekly?

Can you work nights?

Yes No

Employment desired:

Full-time only Part-time only Full- or part-time

When are you available for work?

Number of years completed in high school:

Number of years completed in college:

Number of years completed in business/trade school:

Number of years completed in professional school:

Have you ever been arrested?

Yes No

Have you ever been convicted of a crime which has/has not been expunged or sealed by a court?

Yes No

Do you have any pending cases at the present time?

Yes No

If yes, explain number of convictions, nature of offenses leading to convictions, how recently such offenses were committed, sentences imposed, and types of rehabilitation.

Do you have a valid driver's license?

Yes No

What is your means of transportation to work?

Driver's license number:

Number of accidents in the last three years:*

Number of moving violations in the last three years:*

Please list two references other than relatives or previous employers.

Reference #1 Position:

Reference #1 Company:

Reference #1 Address:*

Reference #1 State & Zip Code:

Reference #1 Telephone:

Reference #2 Position:

Reference #2 Company:

Reference #2 Address:*

Reference #2 State & Zip Code:

Reference #2 Telephone:

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Please list your work experience for the past three years beginning with your most recent job held. If you were self-employed, give firm name.

Employer #1 - State:

Employer #1 - Telephone:

Employer #1 - Address:

Employer #1 - Name of last Supervisor:

Employer #1 - From Date:

Employer #1 - To Date:

Employer #1 - Starting Pay:

Employer #1 - Final Pay:

Employer #1 - Your Last Job Title:

Employer #1 - Reason for Leaving (be specific):

Employer #1 - Jobs you held, duties performed, skills used/learned, advancements/ promotions while you worked at this company:

Employer #2 - State:

Employer #2 - Telephone:

Employer #2 - Address:

Employer #2 - Name of last Supervisor:

Employer #2 - From Date:

Employer #2 - To Date:

Employer #2 - Starting Pay:

Employer #2 - Final Pay:

Employer #2 - Your Last Job Title:

Employer #2 - Reason for Leaving (be specific):

Employer #2 - Jobs you held, duties performed, skills used/learned, advancements/ promotions while you worked at this company:

Employer #3 - State:

Employer #3 - Telephone:

Employer #3 - Address:

Employer #3 - Name of last Supervisor:

Employer #3 - From Date:

Employer #3 - To Date:

Employer #3 - Starting Pay:

Employer #3 - Final Pay:

Employer #3 - Your Last Job Title:

Employer #3 - Reason for Leaving (be specific):

Employer #3 - Jobs you held, duties performed, skills used/learned, advancements/ promotions while you worked at this company:

Do you have any pre-existing injuries or physical limitations, that would prevent you from doing this type of work?

Yes No

May we contact your present employer?

Yes No

Did you complete this application yourself?

Yes No

APPLICATION FORM WAIVER - PLEASE READ CAREFULLY

In exchange for the consideration of my job application by Cleanest By Farr: I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company will run a full criminal background check and may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

PRE-EMPLOYMENT DRUG SCREENING AND MOTOR VEHICLE REPORT CONSENT AGREEMENT

All applicants selected for final consideration for a job with Cleanest by Farr will be required to pass a pre-employment drug screen and Motor Vehicle Report as a condition of employment. DRUG SCREENING I agree to provide a specimen of my urine and give permission to Cleanest by Farr and the laboratory it has selected to conduct a urinalysis required for drug screening. I understand if the drug screen results are positive, a confirming test will be taken using the same specimen. I consent to the release of the test results to Cleanest by Farr. I understand I will not be considered for current position openings if I refuse to sign this authorization, if I refuse to participate in the drug screen, or if I test positive for controlled substances. If I test positive for a controlled substance, I will not be able to reapply for any position within Cleanest by Farr for six (6) months. MOTOR VEHICLE REPORT (MVR) I give permission to Cleanest by Farr to examine my MVR prior to the start of employment. I understand that driving records will be reviewed for both to drivers of company-owned vehicles as well as employees using personal vehicles in the course of company business. I further understand that any job offer made requiring driving duties as well as continued employment shall be contingent upon an MVR meeting the required standards. No new driver will be hired with a “borderline” or “poor” MVR, which may include: Three (3) or more Minor Violations and/or Two (2) or more at-fault accidents over the last three years. One or more Major violation in the past three years: Driving under the influence of alcohol/drugs; failure to stop/report an accident; reckless/dangerous driving; racing; driving while impaired; Driving while license is suspended/revoked; homicide, manslaughter or assault resulting from the operation of a vehicle; attempting to elude a police officer. I will be required to provide a copy of my driver’s license if I am selected for final consideration for a job with Cleanest by Farr. I have read and understand this form.

I do consent. I do not consent and I understand my refusal to consent means I will not be considered for current position openings.

APPLICANT'S STATEMENT

APPLICANT'S STATEMENT Please read carefully and check each paragraph below. A search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by Cleanest by Farr, I am entitled to copies of any such public records obtained by Cleanest by Farr unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

I waive receipt of a copy of any public record described in the paragraph above. I agree.

Typing your name (below) and submitting this form act as your digital signature.

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