Name
*First
Middle
*Last
Telephone No.:
Address
*Street/Apt#:
*City:
*State
County

General Information

*For what position are you applying:
 *Full-Time  Part-Time  Either
Are you 18 years of age or older?Yes   No
If not, please state your age
*Are you legally authorized to work in the United States?Yes   No
Have you ever worked for ProClean?Yes   No
When:
Where:
Position held?
Reason for leaving?
If driving is a requirement of the job for which you are applying, do you have a valid driver's license?
Are you currently working at another job?
Is this a secondary job?
Are you willing to relocate?
List other names under which you have worked or gone to school:
List the name or relatives employed by ProClean and their work location:  None
NameRelationshipWork Location
1.
2.
Have you ever been convicted of a felony? Yes   No
If yes, give date(s)/place(s):
Have you ever been convicted of a misdemeanor? Yes   No
If yes, give date(s)/place(s):
Note: A conviction record will not automatically disqualify you from being considered for employement
Date available for work:
Total hours available per week:
List available hours:
 SUNMONTUEWEDTHUFRISAT
From
To
*Employment History
Date Began / MO./YR
Date Left / MO./YR
Employer
Phone
Address
City:
State
Zip
Type of Business
Supervisor/Title:
Position(s) Held/Salary
Salary
Position
Why did you leave
Add Employer
Education
 Name and LocationYears CompletedDid you graduate?Course of Study
High School
CollegeMajor: Degree:
Other
Employee Emergency Contact
Person to notify in case of emergency
Number
Professional/Personal references
NameOccupationTelephoneYears Known
Skills & Qualifications
How were you referred to our company?
Advertisement  Other Company  Agency  Employment Service  Employee  School  Self  Name of Referral Source:  Other:
Non-Discrimination/Equal Employment Opportunity Statement
ProClean of Arizona, Inc. is committed to non-discrimination, and equal employment opportunity. This commitment is both a matter of law and moral imperative consistent with an intellectual community in which individual differences and diversity are celebrated. Accordingly, discrimination against any individual for reasons of race, color, creed, religion, sexual orientation, national origin, sex, age, disability or veteran status is specifically prohibited.
Providing this information is voluntary. Data collected will be handled confidentially to the extent allowed by law. Disclosure of this information will not result in any adverse employment action.
White, Non-Hispanic . A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black . A person having origins in any of the Black racial groups of Africa.
Hispanic origin, any race . A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures or Origin, regardless of race.
Asian or Pacific Islander . A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian sub-continent, or the Pacific Islands. This area includes China, Japan, Korea, the Philippine Islands and Samoa.
American Indian, Eskimo or Aleut . A person having origins in any of the original peoples of North America, and who maintains identification through tribal affiliation or community recognition.
 Yes  No    Are you a Vietnam-era veteran?
A person who served on active duty for a period of more than 180 days and was discharged with other than a dishonorable discharge and if any part of such active duty occurred: [i] in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or [ii] between August 5, 1964 and May 7, 1975 anywhere in the world.
 Yes  No    Have you been determined to be a special disabled veteran?
A person entitled to disability compensation by the Veterans Administration for a disability rated at 30% or more, or a person discharged for a disability incurred in the line of duty during any era.
 Yes  No    Are you a Vietnam-era veteran? Date discharged:
Any veteran who served on active duty in the US Military ground, naval, or air service during the one year period beginning on the date of such veteran's discharge or release from active duty.
Read the following carefully

CERTIFICATION: I certify that all answers or statements I have made on this application or on my resume or other supplementary materials are true and correct without omissions. I acknowledge that any false statement or misrepresentation on this application or supplementary materials will be cause for refusal to hire or for immediate dismissal from employment at any time during the period of my employment. I authorize this company to contact any of my past employers and/or schools and authorize my past employees and/or schools to furnish any information concerning my previous employment and/or education. I release this company and all persons and organization from all claims and liabilities of any nature arising form the supplying of this information. AT WILL EMPLOYMENT: In consideration of my employment, I agree to conform to the rules and standards of "ProClean" and agree that my employment is for no definite period of time and may be terminated at will at any time by the company or by me, with or without cause and with or without notice. I have read and understand the foregoing statements and accept the same as conditions of employment. PHYSICAL EXAM/DRUG SCREENING: I have no objection to taking a physical/medical examination at any time at the option and expense of the company. I understand that applicants must pass a drug screening urinalysis before employment, and I consent to such procedure, at company expense. If I am a minor, I agree to obtain parental consent for the drug screening
By checking the below and dating, you are agreeing with all aformentioned information.
*Agree:    *Date: