Employment Form - Mosquito Mary's® of Cape Cod

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Personal

Full Name (First & Last)(Required)

First Last

Have you ever been known by any other name?(Required)

Yes

Other name(s) under which you have been previously employed

Permanent Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Email(Required)

Do you have a valid drivers license?(Required)

Yes

Drivers License State

Drivers License Number

Have you ever been employed by this organization before?(Required)

Yes

If yes, list dates of employment

Do you have reliable transportation to and from work?(Required)

Yes

Do you have any family, business, health, or social restrictions or obligations that would prevent you from performing the job responsibilities?(Required)

Yes

Have you ever been convicted of a felony?(Required)

Yes

If yes, list dates, offenses, and disposition.

Convictions are not an automatic disqualification from employment.

Will you comply with the safety work and attendance policies of our organization?(Required)

Yes

Employment Interests

Position(s) Desired or Area of Interest:(Required)

Field Service Technician

Outside Sales Professional

Office Support / Bookkeeper / Assistant

I am interested in a(Required)

Full-time position.

Part-time position.

How were you referred to our organization?(Required)

Employee

Other Company

Agency

Self

Employment Service

Other

How were you referred to our organization?

Name of Referral Source:

Education/U.S. Military Service

Where did you attend high school & college? (Click the + button to add a new row)(Required)

School Name & Address

Major

Years Completed

GPA

Degree/Diploma

Have you ever served in the U.S. Armed Services?

Yes

Other

US Military Duties and special training

Rank held at discharge

References

List at least 3 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)(Required)

Name

Address

Occupation

Years Known

Are you currently licensed to apply pesticides in any state?(Required)

Yes

List the State(s) in which you are licensed and/or certified to apply pesticides along with your license number and experation on your license/certification. (Click the + button to add a new row)(Required)

State

License Number

Expiration Date

Are you willing to undergo training and study to sit for your Pesticide Applicator License?(Required)

Yes

If This Section Blank, Click "Next"

Employment History

Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.

Company Name (Most Recent)

Address

Street Address City State ZIP Code

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes

Did you have another job before this one?(Required)

Yes

Company Name (Second Most Recent)

Address

Street Address City State ZIP Code

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes

Would you like to list another previous job?

Yes

Company Name (Third Most Recent)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes

I agree to a Drug Screening at the company's expense.(Required)

Yes

I agree to a Criminal Background Check.(Required)

Yes

Disclaimer and Signature

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired.

I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to re-quest and receive such information.

In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me.

I also acknowledge that my employment may be terminated, or any offer or acceptance of employment with-drawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.

Digital Signature:(Required)

Printing your First Name + Middle Initial + Last Name will act as your digital signature.

Date(Required)

MM slash DD slash YYYY

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