logo Peterson Cleaning, Inc.
843 North Madison Street
Rockford, IL. 61107
Phone # 815.961.1300
Fax # 815.961.1190
 
Application Information
First Name:
Middle Name:
Last Name:
Address: Apt number
City: State: Zip:
Home Phone #: Cell Phone #:
Date Availible: Social Security #: 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?
Have you ever been convicted of a felony?
Yes No
     
If Yes, Explain:
 
Education
High School: Address:
City: State: Zip:
From: To: Did you graduate?    Yes No  
College: Address:
City: State: Zip:
From: To: Did you graduate?    Yes No Degree:
Other: Address:
City: State: Zip:
From: To: Did you graduate?    Yes No Degree:
 
References
Please list three references        
Full Name: Relationship: Phone #:
Company: Address:
City: State: Zip:
Full Name: Relationship: Phone #:
Company: Address:
City: State: Zip:
Full Name: Relationship: Phone #:
Company: Address:
City: State: Zip:
           
Previous Employment
Company: Supervisor: Phone #:
Address:
City: State: Zip:
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:
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:
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:
My number one reason for seeking employment in a cleaning buisness is:
I am applying to Peterson Cleaning, Inc. because:
My friends describe me as:
My previous (or current) employer describes me as:
When considering dependability, thouroughness, or energy level I feel my strongest area is:
When it comes to getting along with fellow employees I can always be counted on to:
           
 
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.

 
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.