NAME:

CURRENT ADDREESS:

PREVIOUS ADDREESS:

EMERGENCY CONTACT:

AVAILABILITY:

Please indicate the type(s) of work which you would prefer:

Please rank the following services,in order of prefrence that you are willing to provide.

Do you have any reservations about providing service to a client with a pet(s)? *

Would it bother you to provide service to a client that smokes? *

SECURITY

Have you been convicted of a felony and/or served time in the past seven years? if so please describe below.(A conviction will be judged on its own merits with respect to time , circumstances and seriousness.) *

Have you used any name or Social Security Numbers other than those on this application? if so please list. *

INCIDENT CHARGE

CITY STATE

JOB RELATED SKILLS:

Note: Do not fill out any part of this section if you believe it to be non-job related.

EMPLOYMENT REFERENCES:

Your application will not be considered unless every question in this section is answered .Since we will make every effort to contact previous employers the correct telephone numbers of past employers are essential.

Most Recent Employer

Are you Currently working for this employer? *

If yes ,may we contact ? *

Second Most Recent Employer

Third Most Recent Employer

CERTIFICATION AND RELEASE:

I certfy that i have read and understand the applicant note on page one of this form and that the answer given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information omissions or misrepresenations of facts called for for in this application may result in rejection of my application or discharge at any time during my employment .I authrize the company and /or its agents including consumers reporting bureaus, to verify any of his information including ,but not limited to criminal history and motor vehicle driving records . I authorize all persons,schools,companies and law enforcement authorities to release nay information concering my background and hereby release any said persons,schools,companies and law law enforcement authorities from any liability for any damage whatsoever for issuing this information . I also understand that the use of illegal drugs is probhited during employment . If company policy requires I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.