Become a Cleaner

Date (MM/DD/YYYY)

First Name

Middle Name

Last Name

Present Address

City

State

ZIP

Mailing Address

City

State

ZIP

Previous Address (if less than 5 years at present address)

City

State

ZIP

Cell #

Email Address

Driver License #

State Issued

How did you hear about this job?

Driver is a requirement for this job, is your license valid? Driver is a requirement for this job, is your license valid? Yes No

Do you have full time access to a vehicle? Do you have full time access to a vehicle? Yes No

Is your vehicle in good working condition? Is your vehicle in good working condition? Yes No

Is the vehicle covered by liability insurance? Is the vehicle covered by liability insurance? Yes No

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

Are you able to lift 25 pounds or more? Are you able to lift 25 pounds or more? Yes No

Would you have difficulty standing, bending, or kneeling in connection with performing necessary cleaning duties? Would you have difficulty standing, bending, or kneeling in connection with performing necessary cleaning duties? Yes No

Are you allergic to Household Chemicals? Are you allergic to Household Chemicals? Yes No

Are you allergic to cats and/or dogs? Are you allergic to cats and/or dogs? Yes No

Are you afraid of cats and/or dogs? Are you afraid of cats and/or dogs? Yes No

What hours are you available to work on the following weekdays? (State availability for every day of the week, in form from HH to HH. Example, Monday from 2PM to 7PM)

If hired, when can you start work?

Are you presently employed? Are you presently employed? Yes No

If “yes” may we contact your present employer? If “yes” may we contact your present employer? Yes No

Please leave us the contact information of your present employer

Which of the following categories of jobs have you had? Which of the following categories of jobs have you had? House Cleaning Hotel/Motel Restaurant Fast Food Janitorial Sales Homemaker Manufacturing Service Other (explain)

If other:

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.

List below your educational background, including name and school location, high grade completed and major area of study.

Have you ever been convicted of a criminal offense? Have you ever been convicted of a criminal offense? Yes No

If yes, please explain:

Have you ever been bonded? Have you ever been bonded? Yes No

Has your driver’s license ever been suspended? Has your driver’s license ever been suspended? Yes No

If yes, please explain:

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

To what extent would the following job characteristics be attractive to you: MORE FLEXIBLE DAYTIME HRS THAN OTHER JOBS? To what extent would the following job characteristics be attractive to you: MORE FLEXIBLE DAYTIME HRS THAN OTHER JOBS? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: WORKING IN A TEAM ENVIRONMENT? To what extent would the following job characteristics be attractive to you: WORKING IN A TEAM ENVIRONMENT? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: THE OPPORTUNITY TO BECOME A TEAM LEADER? To what extent would the following job characteristics be attractive to you: THE OPPORTUNITY TO BECOME A TEAM LEADER? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: PHYSICAL ACTIVITY AND EXERCISE? To what extent would the following job characteristics be attractive to you: PHYSICAL ACTIVITY AND EXERCISE? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: THE MON-FRI DAYTIME ONLY WORK WEEK? To what extent would the following job characteristics be attractive to you: THE MON-FRI DAYTIME ONLY WORK WEEK? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: HELPING CLIENTS BY KEEPING THEIR HOME CLEAN? To what extent would the following job characteristics be attractive to you: HELPING CLIENTS BY KEEPING THEIR HOME CLEAN? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: A GOOD RELATIONSHIP WITH FELLOW EMPLOYEES? To what extent would the following job characteristics be attractive to you: A GOOD RELATIONSHIP WITH FELLOW EMPLOYEES? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: RECOGNITION FOR GOOD WORK? To what extent would the following job characteristics be attractive to you: RECOGNITION FOR GOOD WORK? Very Great Great Some What Little Very Little

To what extent would the following job characteristics be attractive to you: THE MONEY I CAN EARN? To what extent would the following job characteristics be attractive to you: THE MONEY I CAN EARN? Very Great Great Some What Little Very Little

Check ONLY one (There is no right or wrong answer. We just want to know you better to fill in your schedule) : Check ONLY one (There is no right or wrong answer. We just want to know you better to fill in your schedule) : I NEED this job I WANT this job

Why are you interested in working for Solum Home Cleaning?

Why do you think you’re a good fit for the company?