Personal Information: 

Contractor Name______________________________________ SS# ____________________Tax ID# _________________________ CDL #_____________

Present Address

___________________________________City___________________Zip_____

Phone( _ _ _ ) _ _ _-_ _ _ _ Are you 18 years or older ? YES NO

D.O.B.___________________________

Employment Desired:

Position___________________ Date you can start

_______________________________ Full time_____ Part time_____

Are you employed or providing services on contract now? YES_____ NO_____

May we inquire of your present employer/Clients? YES____ NO___

Provides Services to/Supervisor’s Name________________________________

Phone ( _ _ _ ) _ _ _ - _ _ _ _

High School ______________________________ # of years_______ Did you

Graduate?___________

College__________________________________ # of years _______ Did you

Graduate?___________

Trade School, etc.__________________________ # of years _______ Did you

Graduate?___________

Personal References: Please list 3 non-relatives whom you have known for at

least 2 years.

NAME PHONE RELATIONSHIP YEARS KNOWN

Name/Address______________________________________ Phone ( _ _ _ ) _

_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _

Previous / Current Contract Clients, or Employment:

Please list the past (3) (Most recent first)

Client / Company name Address_______________________________

Phone_________________________________________

Date Start______________________________Date End___________________

Last Position______________________

Pay rate/Start___________Pay rate/End__________Reason for

Leaving______________________________________

Supervisor’s Name________________________________ Phone ( _ _ _ ) _ _ _

- _ _ _ _ Cell. ( _ _ _ ) _ _ _ - _ _ _ _

Duties Required to

Perform__________________________________________________________

_________________________________

________________________________________________________________
_________________________________

Client / Company name Address_______________________________________Phone_____________

____________________

Date Start__________________ Date End___________________ Last

Position______________________

Pay rate/Start_________Pay rate/End_________________Reason for

Leaving_________________________________

Supervisor’s Name___________________________________Phone ( _ _ _ ) _

_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _

Duties Required to

Perform__________________________________________________________

_________________________________

________________________________________________________________
_________________________________

Client / Company name Address_______________________________________Phone_____________

____________________

Date Start__________________ Date End___________________ Last

Position______________________

Pay rate/Start_________Pay rate/End_________________Reason for

Leaving_________________________________

Supervisor’s Name___________________________________Phone ( _ _ _ ) _

_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _

What days or evenings are you available to work?(below)

________________________________________

What hours are you available to work? (enter below)

Are there any activities that would prevent you from working certain days and or hours? (enter below)

WELLNESS2U? _________________________________________________

What do you consider to be your outstanding qualities?

____________________________________________________

What do you consider to be your worst qualities?

__________________________________________________________

What kind of circumstances makes you nervous or tense?

__________________________________________________

Will it affect your work behavior? ________________________________________________________________

_______

Would you take a DRUG TEST ?_________ Since handling cash, would you

take a Polygraph (Lie detector Test?)_______

Have you ever been convicted of a felony or misdemeanor? YES____ NO___

(if YES,

explain)__________________________________________________________

List your favorite hobbies/interest:

1.___________________2.____________________ 3.____________________

List any special skills or Specialized Services:____________________________ ________________________________________________________________

_____________________

Applicant represents that all information given on this application is true and

correct. Applicant hereby authorizes

verification of all references and facts, including but not limited to current and

previous employers, and personal

references. Applicant hereby authorizes

owner/agent/manager to obtain, Company, Personal Credit Reports, background

reports. Applicant understands we contract service providers.

Applicant hereby waives any claim

providing or obtaining said verification or additional information.

and releases from liability any person

facts contained in this application are true and complete to the best of my

knowledge and understand that,

application shall be grounds for dismissal.

if employed, falsified statements of this

Applicant

understands

that incomplete or incorrect information provided in the application

may cause a delay in processing which may result in denial of employment.

I certify that the

_____________________________ ________________________________

Applicant Signature