NEWLYFORMEDCLEANINGCOMPANY

214RAILROADSTREET

MUNCY,PA.17756

EmploymentApplicationApplicantTelephone:________________________

DATE:_______________SocialSecurityNumber:_____________________

YourName:_______________________________________________________________________________________

  Last  First  Middle



Address:    AREYOULEGALLYELIGIBLEFOREMPLOYMENTINTHEUSA?

Areyouover18yearsofage? ____Yes ___No

Ifyouareunder18yearsofage,canyouproviderequiredproofofeligibilitytowork ___Yes ___No

Education:YrsComplete:  FieldofStudy:



HighSchool:___________________________ ___________________ ______________  _____________ 

Buisness/Technical:________________________________________ ______________  _____________ 

College/University:________________________________________ ______________  _____________ 

Other:__________________________________________________ ______________ _____________ 

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Haveyoueverbeenconvictedofanycriminaloffenseotherthanminortrafficviolations?____Yes_____No 



References: List2personalreferenceswhoarenotrelatives

_________________________________________________________________________________________________

NameAddress  Telephone



__________________________________________________________________________________________________

NameAddress  Telephone 

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 

Employment:

EmployerName&Addres sDatesEmployed:From___________ To____________

___________________________  PositionTitle/DutiesSkills: _________________________

___________________________  ReasonforLeaving:________________________________



EmployerName&Addres sDatesEmployed:From___________ To____________

___________________________  PositionTitle/DutiesSkills: _________________________

___________________________  ________________________________________________

___________________________  ReasonforLeaving:________________________________





ProfessionalLicenses,CertificationsorRegistrations:________________ ______________________________________

Listanyotherqualificationsyouwishtobringtoemployersattention____________ _____________________________



Incaseofanaccidentorillnesspleasecontact:

Name:__________________________________________________









Informationtotheapplicant:

Aspartofourprocedureforprocessingyouremploymentapplication,yourpersonalandemploymentreferencesmay

bechecked.Ifyouhavemisrepresentedoromittedanyfactsonthisapplication,and

aresubsequentlyhired,youmay

bedischargedfromyourjob.

Ifnecessaryforemployment,youmayberequiredto:supplyyourBirthCertificateorotherproofofauthorizationto

workintheU.S.haveaphysicalexaminationand/oradrugtest.

Iunderstandandagreetotheinformation

shownabove:

Signature:_____________________________________________________ Date:______________________



Weconsiderallpositionswithoutregardtorace,color,religion,sex,nationalorigin,age,disabilityoranyotherlegally

protectedstatus.Thisorganizationprovidesareasonableaccommodationtoqualifiedindividualswithadisabilityin

accordancewithapplicablelaws.

DoyouhavevalidDriver’slicense:________________ _________

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AdditionalExperienceorQualifications:_________________________________________________________________