Peterson Cleaning, Inc. 8660962-1300 Peterson Cleaning, Inc.
843 North Madison Street
Rockford, IL. 61107
Phone # 815.961.1300
Fax # 815.961.1190
 
Application Information
 
Name (First):* (Middle): (Last):*
Address:* Apt#:
City:* State:* Zip:
Home Phone#:* Cell Phone#:
Date Available:* Desired Salary:
Position Applied for:* City Applied for:*
Email Address: (optional) Birthdate: (optional)

Are you a citizen of the United States?
Yes No

If no, are you authorized to work in the U.S.?
Yes No

Have you ever worked for this company?
Yes No

If so, when?

 
Education
 
High School: Address:
From:    To: City: State: Zip:
Did you graduate?    Yes No
 
College: Address:
From:    To: City: State: Zip:
Did you graduate?    Yes No Degree:
 
Other: Address:
From:    To: City: State: Zip:
 
References
 
Please list references
 
Full Name:* Company:*
Relationship:* Address:*
Phone #:* City:* State:*   Zip:
 
Full Name: Company:
Relationship: Address:
Phone #: City: State:   Zip:
 
Previous Employment
 
Company:*   Supervisor:*   Phone#:*
Address:*
City:* State:* Zip:
Job Title:*   Starting Salary: Ending Salary:
Responsibilities:*
From:*   To:* Reason for Leaving:*
May we contact your previous supervisor for a reference?* Yes No
 
Company:    Supervisor:    Phone #:
Address:
City: State: Zip:
Job Title:    Starting Salary: Ending Salary:
Responsibilities:
From:    To: Reason for Leaving:
May we contact your previous supervisor for a reference? Yes No
 
Company:    Supervisor:    Phone #:
Address:
City: State: Zip:
Job Title:    Starting Salary: Ending Salary:
Responsibilities:
From:    To: Reason for Leaving:
May we contact your previous supervisor for a reference? Yes No  
 
Military Service
 
Branch: From:    To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
 
Questionaire
 
Please answer each question to the best of your ability.

Do you have any physical condition that may limit your ability to perform the job for which you have applied?
*Yes No    If yes, please explain: *

Does heat, standing on your feet, or lifting cause you any difficulties?
*Yes No    If yes, please explain: *

Do you have any cleaning experience?
*Yes No    If yes, please explain: *

What hours are you available to work? Please check all that apply:

AM PM Not Available

AM PM Not Available

AM PM Not Available

AM PM Not Available

AM PM Not Available

AM PM Not Available

AM PM Not Available

 
Voluntary Self Identifcation Form (Applicant)
 
First Name: Last Name:
 
The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Completion of this data is voluntary but we hope that you will choose to fill it out and it will not affect your opportunity for employment or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources Dept. Please return completed forms with your applications of employment.
 
Gender: Male Female
Race/Ethnicity:
 

VETS Self-ID
As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Submission of this information is voluntary and refusal to provide it will not subject you to adverse treatment.

Veteran
Disabled Veteran
Recently Separated Veteran (last 3yrs)
Active Duty Wartime or Campaign Veteran
Armed Forces Service Medal Veteran
Not a Veteran
Do Not Wish to Self Identify
 

Voluntary Self-ID of Disability
As a Government contractor, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out.

Disabilities include, but are not limited to: Blindness, Deafness, Cancer, Diabetes, Epilepsy, Autism, Cerebral Palsy, HIV/AIDS, Schizophrenia, Muscular Dystrophy, Bipolar Disorder, Major Depression, MS, Missing or Partially Missing Limbs, PTSD, OCD, Impairments requiring the use of a wheelchair, Intellectual Disability.

Please mark one below:

Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer
 
Disclaimer and Agreement

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job.

 
*By checking the box to the left, I herby authorize and request any present or former employer, school, police department, financial institution or other person having personal knowledge about me, to furnish bearer (Peterson Cleaning, Inc.) with any and all information in their possession regarding me in connection with an application for employment. A printout or photocopy of this authorization may be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request. I understand this authorization is to be part of the submitted application that I filled out.
 
By pressing the submit button, you agree to the terms expressed above.