Personal Information

Background Check / Consumer Report

I agree to any Background Checks, Consumer Reports, and/or Drug Testing, and agree to all the terms and conditions laid out in the Authorization For Consumer Reports: YesNo

List all addresses during the past 7 years






Position Applying For

Select all that Apply:

Full TimePart Time DaytimeEvening
Office CleaningFloor MaintenanceCarpet MaintenanceLead PersonSupervisor

Do you have experience in any of the following areas?

Commercial Office CleaningFloor Maintenance of Commercial TilingCarpet MaintenanceSupervisory Work


Availability

Date Available (eg. ##/##/####)

Hours Available / Wk.

Will you work Overtime? YesNo

Days of the week / hours available

Monday YesNo

Tuesday YesNo

Wednesday YesNo

Thursday YesNo

Friday YesNo

Saturday YesNo

Sunday YesNo


Restrictions

Are there any restrictions on the amount of weight you can lift? YesNo

If yes, how many lbs?

Do you have any impairments, physical or mental, that would substantially limit your ability to perform the job for which you are applying? YesNo


Disclosures

Do you have friends or relatives working here? YesNo

Do you have your own transportation? YesNo

Do you have a valid Driver’s License? YesNo

Do you speak fluent English? YesNo

Are you authorized to work in the United States? YesNo

Are you currently employed? YesNo

Do you plan on continuing employment if hired? YesNo


References

Please list 3 references whom are not related to you.


Work History

Most Recent Employer

I am currently employed here YesNo

First Day of Employment (eg. ##/##/####) Final Day of Employment (eg. ##/##/####)

Additional Employer

I am currently employed here YesNo

First Day of Employment (eg. ##/##/####) Final Day of Employment (eg. ##/##/####)

Additional Employer

I am currently employed here YesNo

First Day of Employment (eg. ##/##/####) Final Day of Employment (eg. ##/##/####)

Additional Employer

I am currently employed here YesNo

First Day of Employment (eg. ##/##/####) Final Day of Employment (eg. ##/##/####)


Agreement / Submission

Please do not contact these Employers

I hereby certify that the information contained in this application is true and correct, and I authorize the representatives from Rock Valley Industries, LLC to contact any of my employers, current or former, and other references, unless otherwise stated, for the purpose of collecting information regarding my employment with them.

I understand that if I am employed by Rock Valley Industries, LLC, any misrepresentation of the facts as stated on this application form is sufficient cause for dismissal. I also understand that by completing this application, Rock Valley Industries, LLC is not bout in any way to hire me.