Employment Application SmartClean® 755 SE Frontier Avenue, Suite 101 Waukee, Iowa 50263 515-331-8940 Printable Employment Application In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regards to race, color, religion, sex, national origin, age, marital status, or non-job-related disability. Date of Application:* MM slash DD slash YYYY Position Applied for:* Name:* First Middle Last Social Security No.:* Telephone:*Email:* Current Address:*List your address of residency for the past 3 years. Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Additional Addresses Needed?* Yes No Previous Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this address? Background with SmartClean®If hired, can you submit documentation verifying your identity and your legal right to work in the U.S.?* Yes No Have you worked for this company before?* Yes No If yes, where?* Dates:* Please fill in from (date) to (date) Example: March 2015 - September 2017Former Rate of Pay:* Former Position:* Reason for Leaving:* Are you currently employed?* Yes No If not, how long since your last employment?* Who referred you? Rate of Pay Expected:AVAILABILITYFull-Time or Part-Time?* Full Time Part Time Hours Per Day?*Hours Per Week?*Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the job description]?* Yes No If Yes, please explain:*Employment HistoryAll applicants must provide the following information on all employers during the preceding 2 years. List complete mailing address, street number, city, state and zip code. (NOTE: List employers in reverse order starting with the most recent. Employer #1 Name (most recent): Employer #1 Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer 1 Dates: (Sample: March 2018 - April 2020)Employer 1 - Position Held: Employer 1 - Salary/Wage: Employer 1 - Reason for Leaving: Do you wish to add other Employers?* Yes No Employer #2 Name: Employer #2 Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer 2 Dates: (Sample: March 2014 - April 2016)Employer 2 - Position Held: Employer 2 - Salary/Wage: Employer 2 - Reason for Leaving: Employer #3 Name: Employer #3 Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer 3 Dates: (Sample: March 2018 - April 2020)Employer 3 - Position Held: Employer 3 - Salary/Wage: Employer 3 - Reason for Leaving: Education:Highest Grade Completed:Primary Grades: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 Name of Last School Attended: City Location of Last School Attended: Experience & Qualifications - OtherList any other applicable experience / training. Or upload your resume below:Resume UploadAccepted file types: pdf, doc, docx, Max. file size: 32 MB.If uploading a resume, please use one of these formats: .pdf, .doc, .docx. .TO BE READ AND SIGNED BY THE APPLICANT:By typing my name and submitting this form, I have certified that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment decision. (Generally, inquiries regarding medical history will be made only if and after a condition offer of employment has been extended.) I hereby release employers, school, health care providers and other person from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. Applicant's Signature: CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ