Application

Application
For Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applied For* Desired wage or salary range* How did you learn about us Radio Advertisement Employment Agency Internet Friend Relative Job Fair Walk In Other

Name and Address

First Name* Middle Name Last Name* Social Security No.* Street #* Street* City* State* Zip Code* Home Phone Cell Phone E-Mail Address

Additional Information

Are you 18 years or older?* Yes No Are you a Disabled Individual?* Yes No Type of Disability

Have you ever filed an application with us before?* Yes No If yes, give date: Have you ever been employed with us before?* Yes No If yes, give date and reason for leaving: May we contact your present employer?* Yes No Are you currently subject to a non-compete, confidentiality, non-disclosure, employment agreement or any offer agreement potentially restricting the scope of your work with a future employer?* Yes No Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Proof of citizenship or immigration status will be required upon employment.* Yes No On what date would you be available for work?* Are you available to work:* Full Time Part Time Shift Work Temporary Are you currently on "lay-off" status and subject to recall?* Yes No Can you travel if a job required it?* Yes No Have you been convicted of a crime other than a minor traffic infraction? Conviction will not necessarily disqualify an applicant from employment.* Yes No If Yes, please explain:

Education

High School or Equivalent

Name and Address of School Course of Study Years Completed Diploma/Degree

Undergraduate College, University, Trade School

Name and Address of School Course of Study Years Completed Diploma/Degree

Graduate Professional

Name and Address of School Course of Study Years Completed Diploma/Degree

Other (Specify)

Name and Address of School Course of Study Years Completed Diploma/Degree

Indicate any foreign languages you can speak, read and/or write.

Language One

Language Speak: Fluent Good Fair Read: Fluent Good Fair Write: Yes No

Language Two

Language Speak: Fluent Good Fair Read: Fluent Good Fair Write: Yes No

Language Three

Language Speak: Fluent Good Fair Read: Fluent Good Fair Write: Yes No

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Military Service

Were you ever in the U.S. Military or Government Service?* Yes No If yes, what military branch or agency? Are you a Disabled Veteran? Yes No Are you a Newly Seperated Veteran? Yes No Are you a Armed Forces Service Medel Veteran? Yes No Medal Awarded Other Protected Veteran? Yes No Describe Final rank or Government service level: Served From Date of Discharge Describe any job-related training received in the United States military.

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.

Employer Supervisor Hours/Week Address.. Start Date End Date Phone Number(s) Starting Salary Final Salary Job Title Reason for Leaving Work Performed

Any additional information you would like us to know

Specialized Skills

Skills PC/Typewriter Excel Word Power Point Adobe Illustrator Web Development Equipment Operated Other Skills State any additional information you feel may be helpful to us in considering your application.

References such as previous supervisor or co-worker who can provide professional references.

Name Phone Address

I am capable of performing the following job functions:

Able to lift 40 lbs.

Able to maintain physical activity for 2 - 4 hour intervals.

Able to rotate upper body 180 degress (90 degrees left 90 degrees right).

Able to use stairs.

Flexible in all major joints.

Able to use both arms over head.

Able to maintain balance while looking up.

Minimum of 20/40 vision, or wear corrective lenses to correct to 20/20 vision.

Able to tell time.

Able to read and write on an 8th grade level.

Can you with or without reasonable accommodations perform the essential functions of this job? If you have any questions about the functions of the job, please ask the interviewer before answering this question. Yes No

Affirmative Action Data Record

Employess are treated during employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of the Data Record is optional. If you choose to volunteer the requested information please note that all Data
Records are kept in a Confidential File and are not a part of your Application for Employment or Personnel file.

Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

Name and Address

First Name Middle Name Last Name* Social Security No. Number Street City State Zip Code Home Phone Cell Phone E-Mail Address

How did you learn about us Advertisement Employment Agency Internet Friend Relative Job Fair Walk In Other Current Job Gender Male Female Birthdate Ethnicity White Black Hispanic Asian/Pacific Islander American Indian/Alaskan native Other

Applicant's Statement

I specifically authorize Safari Contract Cleaners, and those acting on behalf of Safari Contract Cleaners, to investigate and/or make inquiry into my background as may be necessary in arriving at an employment decision, including, but not limited to, a criminal background check, a consumer reporting agency report,
an MVR (motor vehicle report) and workman’s compensation activity report. I release Safari Contract Cleaners from any liability, including a potential claim for defamation, related to the completion or undertaking of my pre-employment background check.

This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood
that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or inter-view(s) may result in discharge. If employed, I agree to abide by all policies, rules and procedures of the Employer. I also understand that I may be required to take a drug test or participate in a random drug pool
as a condition of employment.

I hereby authorize the use of photocopies of this section of the application for employment for acceptance by all persons and parties as an original for the release of any and all information that is relevant to the consideration of the application of employment. I agree to release all such persons and parties from any
claim or liability for providing such information to the company.

Thank you for your application, we will be in contact with you shortly. If you do not hear form us with in 48 hours please call us at 1-800-435-2684