STAR INTERNSHIP INITIATIVE



Application for Fresh Starts Janitorial Employment TrainingPERSONALFull Name: LastFirstMiddle InitialCurrent Address: StreetCityState ZipTelephone Number: ( ) Home / CellUse the number that allows for us to easily get a hold of you.Alternate Telephone Number (any other number where you can be reached?): ( ) Are you 18 years of age or older? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a military veteran? FORMCHECKBOX Yes FORMCHECKBOX NoAre you legally able to work in the United States? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, dates ofactive duty: to Have you ever been known by any other name(s) that we will require to verify the information on this application? GENERAL BACKGROUNDHave you ever held a janitorial or maintenance related job? When/where?: ___________________________________________________________________________________Are you available to work Monday – Friday from 5 – 10pm? FORMCHECKBOX YES FORMCHECKBOX NOSchedule Availability: __________________________Date you can start: Do you have any certificates, licenses, or endorsements that are applicable for this job? FORMCHECKBOX Yes FORMCHECKBOX No; If Yes please list: ___________________________________________________________________________________________________________________Other training or skills that will assist in job placement: ___________________________________________________________________________________________________EXPECTATIONSAre you physically able to meet the expectations of a janitorial position; including operating vacuum cleaners, standing for 2 or more hours at a time, lifting, and bending? FORMCHECKBOX Yes FORMCHECKBOX No Are you willing to commit to a 2-week training period, including showing up on time and prepared to work for all scheduled work shifts?: __________________ You will be working closely with other staff and interns. Are you willing to take feedback and work with others to complete the job duties? ___________________EMPLOYMENT HISTORYFormer Employment: Please list employers, starting with the most recent employer. Explain all gaps in employment pany Name: Job Title: Address: StreetCityStateContact/Supervisor: NameTitleContact Information (phone/email)Job Duties: ______________________________________________________________________________________________________________________________________________________________________________________________________________Dates of employment: _____/_____/________ to _____/_____/______ Reason for leaving:_________________________________________________________________Pay rate: $ ________________ FORMCHECKBOX per hour FORMCHECKBOX weekly FORMCHECKBOX bi-weekly FORMCHECKBOX annually FORMCHECKBOX other ____________Company Name: Job Title: Address: StreetCityStateContact/Supervisor: NameTitleContact Information (phone/email)Job Duties: ______________________________________________________________________________________________________________________________________________________________________________________________________________Dates of employment: _____/_____/________ to _____/_____/______ Reason for leaving:_________________________________________________________________Pay rate: $ ________________ FORMCHECKBOX per hour FORMCHECKBOX weekly FORMCHECKBOX bi-weekly FORMCHECKBOX annually FORMCHECKBOX other ____________Company Name: Job Title: Address: StreetCityStateContact/Supervisor: NameTitleContact Information (phone/email)Job Duties: ______________________________________________________________________________________________________________________________________________________________________________________________________________Dates of employment: _____/_____/________ to _____/_____/______ Reason for leaving:_________________________________________________________________Pay rate: $ ________________ FORMCHECKBOX per hour FORMCHECKBOX weekly FORMCHECKBOX bi-weekly FORMCHECKBOX annually FORMCHECKBOX other ____________May we contact your former employers to verity this information? FORMCHECKBOX Yes FORMCHECKBOX NoMay we contact your present employer? FORMCHECKBOX Yes FORMCHECKBOX NoThe law prohibits discrimination in hiring due to age, race, color, creed, sex, national origin, religion or disability.Please provide any additional information about your abilities or interests that make you a good candidate for this position: ___________________________________________________________________________________________________________________I acknowledge that this information reported in this application is accurate to the best of my knowledge; omissions or misrepresentation of facts is cause for dismissal.Signature: ___________________________________________ Date: _____________ ................
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