APPLICATION FOR EMPLOYMENT

3354 Goodman Rd E Southaven MS 38672 662-510-5715
APPLICATION FOR EMPLOYMENT
Eco Clean LLC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:
Applicant Information
Applicant Name *
Application Date *

Month Day Year
Date
Birth Date *

Month Day Year
Date
Phone Number *
Social Security Number *
Street Address *
City, ST, Zip *
Email *
example@example.com
Employment Desired
Position applied for
How did you hear about this position?
Availability *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Desired Hours *

Full Time Part Time Mornings Evenings
Date Available to Begin *

Month Day Year
Date
Employment History
Please list the last 3 jobs you have had (including your current job, if applicable

Employer: May we contact this employer? Address: City, ST, Zip: Phone Number: Last position held and description of responsibilities:
#1
Employer *
Is this your current employer? *
May we contact this employer? *
Start Date *

Month Day Year
Date
End Date (if not current)

Month Day Year
Date
Street Address
City, ST, Zip
Phone Number
Starting Pay
Ending Pay
Last position held and description of responsibilities
Supervisor
Supervisor Phone Number
Supervisor Email
example@example.com
Reason for leaving (or wanting to leave if currently employed)
City, ST, Zip
Additional Information
List any professional, trade, business, or civic activities and offices held. You may exclude memberships that would reveal gender, race, religion, national origin, ancestry, age, disability, or any other protected status.
List any languages other than English that you can speak, read, or write that could be of benefit to the position applied for.
Language
Ability

Speak Read Write
Mastery

Fluent Good Fair
Have you ever applied with or been employed by Eco Clean LLC? *

Yes No
If yes, when?
Do you have any friends or relatives employed by this company? *

Yes No
If yes, please provide their name(s) and relationship to you
Are you currently employed? *

Yes No
May we contact your employer? *

Yes No
If hired, can you provide proof of U.S. citizenship OR proof of your legal right to work in the U.S.? *

Yes No
Do you or will you in the future require sponsorship for employment visa status (e.g. H-1 B visa status)? *

Yes No
Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation? *

Yes No
If hired, do you have a reliable means of transportation to and from work? *

Yes No
Do you have a valid driver's license? *

Yes No
If hired, would you be able to travel, or work overtime or weekends as needed? *

Yes No
Criminal History
Please respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for convictions for which the criminal record has been expunged or sealed by the court or, misdemeanor convictions for which any probation has been completed and the case dismissed by the court. Furthermore, please note that no applicant will be denied employment solely on the grounds that they have been charged, committed, or convicted of (or pleaded guilty or no contest in) a criminal offense, or solely on an affirmative answer. The nature, date, surrounding circumstances and relevance of the offense to the position(s) applied for will be considered. A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.
Have you ever, under your name or any other name, been convicted of (or pleaded no contest to) a felony or misdemeanor? *

Yes No
Have you ever, under your name or any other name, been convicted of a crime, which resulted in your being in prison and/or jail and released from prison and/or jail or paroled? *

Yes No
If yes to either question above, please fully explain when, where, and of what you were convicted, and the result of the case(s)
Are you currently under arrest, or released on bond on your own recognizance, pending trial for a criminal offense? *

Yes No
POLICIES
Please initial on every line stating that you have read and understand the policy.
Equal Employment Opportunity Statement
Eco Clean LLC is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all federal, state, and local laws providing for equal employment opportunities, as well as laws related to terms and conditions of employment. Eco Clean LLC desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age, or any other status protected by federal, state, or local laws. Eco Clean LLC will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.
Initial *

Clear
Discrimination and Sexual Harassment Policy Statement
Eco Clean LLC will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, or offensive work environment.
Initial *

Clear
Disclosure to Applicants Concerning Drug/Alcohol Testing
If you are offered a position within Eco Clean LLC, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. The individual undergoing the testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.
Initial *

Clear
Complete and Accurate Information
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time lapsed before discovery.
Initial *

Clear
At-Will Employment
I understand and agree that if I am employed, my employment will be “at-will”, which means that Eco Clean LLC may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, Eco Clean LLC will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superseded and that no promise or representation contrary to the forgoing is binding on the company unless made in writing signed by the company’s president.
Initial *

Clear
Company Obligation
I understand and agree that Eco Clean LLC’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that Eco Clean LLC is under no obligation to hire me as the result of accepting this completed application.
Initial *

Clear
Policy Against Violence
The safety and security of our employees, residents, tenants, vendors, contractors, and the general public are of essential importance. Therefore, threats or acts of violence made by an employee against another person’s life, health, well-being, family, or property will not be tolerated. Employees who violate this policy will be subject to discipline up to and including immediate termination.

The following are prohibited:

- Any act or threat of violence made by an employee against another person’s life, health, well-being, family, or property.

- Any act or threat of violence, including but not limited to, intimidation, harassment, or coercion.

- Any act of threat of violence which endangers the safety of employees, residents, tenants, vendors, contractors, or the general public.

- Any act or threat of violence made directly or indirectly by words, gestures, symbols, or email.

- Use or possession of a weapon on Eco Clean LLC’s premises.

It is a requirement that employees report to their supervisors or Human Resources, in accordance with this policy, any behavior that compromises Eco Clean LLC’s ability to maintain a safe work environment. All reports will be investigated immediately and kept confidential, except where there is a legitimate need to know.
Initial *

Clear
Reporting Workplace Injuries
I understand that I am required to report any and all workplace accidents, injuries, or illnesses that occur to me or to someone I witness to an owner or manager of Eco Clean LLC.

I understand that the reporting of injuries or illnesses help identify potential safety hazards. I understand that the law requires all worker’s compensation claims to be submitted within 24 hours of the occurrence. I am also aware that I must turn in any and all injuries or illnesses no matter how small or insignificant they may seem at the time.

Furthermore, I am aware that if I do not turn in all pertinent information regarding the injury or illness within 24 hours of the injury or illness occurring, I may be denied worker’s compensation benefits.
Initial *

Clear
I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.
Name *
Date *

Month Day Year
Date
Signature *

Clear
New Hire Payroll Data
Employee Name *
Social Security Number *
Street Address *
City, ST, Zip *
Phone Number *
Birthday *

Month Day Year
Date
Gender *

Male Female
Marital Status

Married Single
Filing Status

Married Single
Dependents
Additional Amount $
Emergency Contact
Relationship
Contact Phone Number
Authorization for Pre- and Post- Employment Checks, Searches, and Investigations
First Name *
Middle Name *
Last Name *
Maiden Name
Social Security Number *
Birthday *

Month Day Year
Date
Phone Number *
Email *
example@example.com
Street Address *
City, ST, Zip *
In applying for employment with Eco Clean LLC, I hereby authorize the company, or any designated agent(s) working on the company’s behalf, including but not limited to reporting agencies or professional investors, to obtain and review those reports checked off below as well as following up on information presented in the reports. Eco Clean LLC or its agents may also request these reports and information during any employment as a condition of continued employment. My consent extends to any possible investigations performed during the employment, including those related to complaints of discrimination, harassment, theft, or other conduct.

It is my understanding that the information being obtained will not be used in violation of any federal or state equal opportunity law or regulation, and that, before any adverse action is taken, based upon review of such investigative consumer report, I will be provided with a copy of said report as well as a summary of consumer’s rights.

I understand the nature and scope of said inquiries may include, but are not limited to, verification; inspection and/or reporting of any lawfully available records or information pertaining to work history; social security number; education; workers’ compensation claims; criminal and civil court related actions; driving history (including traffic related offenses); personal financial status (including consumer credit reports); and any other information available from any public or otherwise documented record. It may also include inquiries regarding any past or present business, or professional or personal activities.

I hereby state that to the best of my knowledge all information I have provided to Eco Clean LLC and any reporting agency, in any form, is true and accurate. I understand that any misrepresentation made to Eco Clean or reporting agency by me will exclude me from further consideration as a candidate for employment or advancement and may result in termination of my employment with Eco Clean LLC if I am hired or advanced by the company before such misrepresentation is discovered. I fully understand this authorization, waiver, and release of liability is not an offer or a contract for employment by Eco Clean LLC. It is also understood that Eco Clean LLC operates under an “at-will” employment policy and that this authorization and release does not alter or affect this policy in any manner.
Please initial under each of the following sections stating that you have read and understand the authorization.
Authorization to Obtain Criminal Information
I hereby authorize Eco Clean LLC, a reporting agency, or investigator to request, obtain, and examine all records that may relate to my arrest, conviction and/or imprisonment at any time prior to this date, to the extent permitted by law.
Initial *

Clear
Authorization to Obtain Credit Reports
I hereby authorize Eco Clean LLC, a reporting agency, or investigator to make inquiry into, investigate, and examine all records that may relate to my current or past credit worthiness; such information to include (but not be limited to) a retail credit report provided by any of the commercial retail credit reporting companies.
Initial *

Clear
Authorization to Obtain Background Report
I hereby authorize Eco Clean LLC, a reporting agency, or investigator to request an employment background report.
Initial *

Clear
Authorization to Obtain Educational Background
I hereby authorize Eco Clean LLC or reporting agency to request an educational background report.
Initial *

Clear
Authorization to Obtain Motor Vehicle Records
I hereby authorize Eco Clean LLC, a reporting agency, or investigator to acquire and examine a copy of my current motor vehicle record.
Initial *

Clear
I hereby consent, authorize, and permit Eco Clean LLC, its agents, assigns, and all reporting agencies to conduct in whole or in part the checks, searches, and investigations listed herein above.
Name *
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

APPLICATION FOR EMPLOYMENT

Applicant Information

Employment Desired

Employment History

#1

Additional Information

Criminal History

POLICIES

Equal Employment Opportunity Statement

Discrimination and Sexual Harassment Policy Statement

Disclosure to Applicants Concerning Drug/Alcohol Testing

Complete and Accurate Information

At-Will Employment

Company Obligation

Policy Against Violence

Reporting Workplace Injuries

New Hire Payroll Data

Authorization for Pre- and Post- Employment Checks, Searches, and Investigations

Authorization to Obtain Criminal Information

Authorization to Obtain Credit Reports

Authorization to Obtain Background Report

Authorization to Obtain Educational Background

Authorization to Obtain Motor Vehicle Records