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Application Date

First name

Last name

Address

Address Line 2

City

State

Zip Code

Phone

Referred By

Are you legally eligible to work in the U.S.?

Yes

Do you have a valid driver's license?

Yes

Work History/Experience

Please list 3 work experiences

Employer 1:

Employers Name

Position Held

Supervisors Name

Phone

Start Date

End Date

May we contact this employer?

Yes

If no, explain:

Duties:

Reason for leaving:

Employer 2:

Employers Name

Position Held:

Supervisors Name:

Phone

Start Date

End Date

May we contact this employer?

Yes

If no, explain:

Duties:

Reason for leaving:

Employer 3:

Employer's Name:

Position Held:

Supervisors Name

Phone

Start Date

End Date

May we contact this employer?

Yes

If no, Explain:

Duties:

Reason for leaving

References

Please List 3 References

Name

Phone

Name

Phone

Name

Phone

False information can lead to termination. I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if this company at any time learns of false information provided on this application form and related documents. You may contact any former employers. I hereby release MinterFresh Cleaning Services ®, its affiliates, successors, assigns, and all references from any liability that might be claimed because of information provided by such references. I agree that I will follow all MinterFresh Cleaning Services ® policies, rules, and procedures. I understand that MinterFresh Cleaning Services ® reserves the right to add, change, and/or delete any policies, procedures, work rules, and/or benefits at any time. I agree to make myself available for random drug testing.

Type full name to acknowledge above statement

Signature