QUALITY ASSURED CLEANING APPLICATION
Please fill out form completely for employment consideration.

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age,
national origin or handicap. We are an equal opportunity employer.
 
Personal Information
Last Name:
First Name:
Middle:
Birthdate:
Street Address:
S.S.#
City:
State:
Zip:
Home Phone:
Cell:
Email:
 
Are you at least 18 years or older?
Yes No
*If not employment is subject to verification of minimum legal age.
 
Desired salary
 
Have you ever applied for employment and/or been employed by our company in the past?
Yes No
If yes, when and where?
How did you learn about our company?
 
Are you legally eligible for work in the United states?
Yes No
When will you be able to work?
 
All job positions in this company include and may be repetitiously; Lifting- (General Cleaners up to 50lbs by oneself, and more with additional help from team general cleaning crew. Construction cleaners up to 50 lbs by oneself and more with addtional team crew cleaners).It is your responsibility to assess the max weight of material that you handle and secure the help needed to complete the task. Bending, Kneeling, Scrubbing floors, Reaching, Dusting, Climbing, Vaccuming, Window washing, Bathroom Cleaning, Cleaning Chemicals use, Stair climbing, Mopping, Sweeping, Trash removal, Debris clean up, Ladder use, Stocking, Commercial equipment operations, communications, Tim shiftresponsibilities,Reporting responsibilities, Fast paced cleaning, Harness and secured safety lines for 1st floor and higher within 6ft exterior walls for exposed exteriors (must be trained on specific job details and certified for some equipment operations),.
 
Are there any reasons (medical or other) for which no be able to perform the job duties involved with this company (with reasonable accomodation)?
Yes No
If yes; Please explain
 
Have you been convicted of felony?
Yes No
If so, explain
 
Do you have valid Ohio driver's license?
Yes No
If yes;
DI#
State issued
 
Do you have your own transportation? (Can not take bus, and may not be dropped off or picked up due to unsecured responsibility of commitment).
Yes No
You are required to drive your own transportation to from work.
 
Emergency Contact Information-
Spouse or person to contact incase of an emergency on your behalf
Full name:
Phone1
Phone2
Address
Relationship to you
 
*Additional emergency contact person
Full name:
Phone1
Phone2
Address
Relationship to you
 
Education
High School:
Course of Study:
No. Of Years Completed:
Did You Graduate?
Yes No
Degree, GED, or Diploma:
Other School:
Course of Study:
 
Military Service
Branch
From
to
Rank at Discharge
Type of Discharge
If other than honorable, explain
 
Employment History
Beginnning with current or most recent employment
Company:
Phone
Address
Supervisor
Job title
Starting salary
Ending salary
Responsibilities
Start date
End date
Reason for leaving?
 
May we contact this employer?
Yes No
 
Company:
Phone
Address
Supervisor
Job title
Starting salary
Ending salary
Responsibilities
Start date
End date
Reason for leaving?
 
May we can contact this employer?
Yes No
 
Company:
Phone
Address
Supervisor
Job title
Starting salary
Ending salary
Responsibilities
Start date
End date
Reason for leaving?
 
May we can contact this employer?
Yes No
 
References- Please list two professional references
Full name
Relationship
Company
Years acquainted
Address
Phone
 
Full name
Relationship
Company
Years acquainted
Address
Phone
 
Additional Information-
Any information that you would like to state
 
Disclaimer and Signature
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.
Signature
Date
 
I authorize and permit Quality Assured Cleaning, Inc. to perform any necessary background checks including but not limited to; arrest record(s) and filing from local, state and federal jurisdictions.

I do hereby release Qaulity Assured Cleaning, Inc. and governing agencies and all individuals from any liabilities connected to such background check.
DATE
 
20
SIGNATURE
NAME
ALIAS
DATE OF BIRTH
SEX
RACE
SOCIAL SECURITY NUMBER
AGENCY REQUESTING RECORD
SIGNATURE OF AGENT MAKING REQUEST
This is a copy of the arrest record on file at the Franklin County Sheriff's on the above named subject. It is only a check by name and not by fingerprints, and is not verified as to the true identity of the subject in question.
 
DATE
 
Charge
 
By
Date
What is the result of this math equation?
7 + 5 =
 
 
 
 
SERVICES OVERVIEW
Assisted Living Facilities
Restaurants
Hospitals
Schools
Recreational Facilities
Office Buildings
Supermarkets
Living Complexes
Hotels
Factories
Medical Office Buildings
 
 
CONTACT INFO
Address:
6407 Nicholas Dr.
Columbus oh. 43235
Phone:
(O) 614-798-1505 \ (F) 614-798-1505
 
 
 
 
 
 
 
 
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