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 TimeDaytimeEvening
    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.