KSB Services, Inc.

                                                                              "The liberator's of dirt and grime."

                                                                                 To contact us: sales@ksbservicesinc.com

                                             

CLICK ON FILE/PRINT TO PRINT THIS PAGE AND MAIL IN APPLICATION.
EMPLOYMENT APPLICATION
  MAIL APPLICATION TO: KSB Services, Inc. PO Box 68 CT. 06484

(It is the policy of KSB Services, Inc. to provide equal employment opportunities to all applicants and employee without regard to any legally protected status such as race, color,

religion, gender, national origin, age, disability or veteran status. Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof

of employment authorization and identity (valid driver's license, birth certificate, green card, etc.) within three days of being hired. Failure to submit such proof within the required

time shall result in immediate employment termination.)

Personal Information: Applicant
Name:___________________________________________________________
Address:____________________________City/State/Zip___________________
Number years at address:____ Daytime phone:___________________________
Evening phone:___________________ Cell phone:________________________
Social Security Number:_________________________ Date of Birth:__________

1. Who should be contacted if you are involved in an emergency?
Contact Name:______________________________ Relationship to you:_____________
Address:__________________________________City/State/Zip:___________________
Daytime phone:____________________ Evening phone:____________________
2. Job Position Applied For:_______________________________________________
3. Referral Source:Who referred you to our company?____________________________
4. Have you applied to our company previously?___ Yes___ No If yes, when?__________
5. Are you at least 18 years old?______ Yes _____ No
6. How will you get to work? _____________________________________
7. Driver's License Number:_______________ What state issued your license?________
8. Are you willing to work any shift, including nights & weekends?_____ Yes ______ No
If no, please state any limitations:_________________________________________
9. If you are offered employment, when would you be available to begin work? _________
10. Are you legally eligible for employment in the United States?____ Yes ___ No
11. Are you able to perform the essential functions of the job position with or without
reasonable accommodation?__ Yes __ No
What reasonable accommodation, if any, would you require?____________________
12. Have you ever been convicted of any crime, including traffic violations? ___ Yes___No
If yes, please describe: ________________________________________________
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Applicant Employment History: List your current or most recent employment first.
Last date you were employed?__________________________________________
If not employed now, why?_____________________________________________

Employer Name: ___________________________________________
Address:________________________________ City/State/Zip:____________________
Job Duties:____________________________Reason for Leaving:__________________
Last Hourly Rate or Salary Rate: _________Dates of Employment (Month/Year):_______
Telephone: ____________________
Employer Name:___________________________________________
Address:_____________________________________City/State/Zip:________________
Job Duties:_____________________________ Reason for Leaving:________________
Last Hourly Rate or Salary Rate: ________Dates of Employment (Month/Year):________
Telephone:_____________________
Employer Name:___________________________________________
Address:______________________________________City/State/Zip:_______________
Job Duties:_________________________Reason for Leaving:_____________________
Last Hourly Rate or Salary Rate: ______Dates of Employment (Month/Year):__________
Telephone:___________________
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Applicant's Education and Training: List your education and training.
High School Name and Address ____________________________________________
Last Grade? ___ 9 ____ 10 ____ 11 ____ 12 Diploma?_____ Yes_____ No
College Name & Address_____________________Did you receive a degree?_____ Yes ____ No
If yes, degree received:___________Other Training (graduate, technical, vocational):____________
Awards, Honors, Special Achievements:______________________________________
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Applicant's Skills: Check those skills that you have. List any other skills that may be useful for the job you are seeking.
Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill.
                                                                                                   (One represents poor ability, while five represents exceptional ability.)
Skill                                          Years of Experience                         Ability or Rating
[ ] Buffing                                  __________________                     1 2 3 4 5
[ ] Strip & Wax                         __________________                     1 2 3 4 5
[ ] Carpet Cleaning                     __________________                     1 2 3 4 5
[ ] Auto Burnisher                       __________________                    1 2 3 4 5
[ ] Window Washing                  __________________                    1 2 3 4 5

List any other skills here that may be useful for the job you are seeking.
_____________________             __________________          1 2 3 4 5
_____________________             __________________          1 2 3 4 5
_____________________             __________________          1 2 3 4 5
_____________________              __________________         1 2 3 4 5
List any personal attitude skills here that may be useful for the job your are seeking. (ex: teamwork, dependable, self-motivator.)
_____________________             __________________           1 2 3 4 5
_____________________            __________________            1 2 3 4 5
_____________________            __________________            1 2 3 4 5
Additional Comments you may have: _______________________________________________
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References: List any two unrelated people who would be willing to provide a reference.
Name:___________________________________Address:_______________________________
City/State/Zip:________________________________Telephone:_______________________
Relationship:_______________________

Name:______________________________Address:___________________________________
City/State/Zip:________________________________Telephone: _______________________
Relationship:_______________________

Please provide any other information that you believe should be considered:_____________________
______________________________________________________________________________
______________________________________________________________________________

CERTIFICATION
I certify that the information provided on this Application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment

commences, immediate termination. I further understand it is my responsibility to advice KSB Services, Inc., if there should be any changes to my statements above, and failure to do so my result in disciplinary

action up to and including dismissal. I understand that there is no contract or guarantee of hours of employment for a specified time, and accordingly, during the introductory period, or anytime thereafter, of KSB

Services, Inc. my end the employment relationship, at will, anytime with our without cause. My signature below grants consent to verify all information and statements made on this application, including

employment information. My signature below also grants consent to conduct an criminal investigation as a condition of my employment.

I authorize KSB Services, Inc. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely

communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous

employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, the employment relationship will be

entirely voluntary in nature. In other words, with appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer

would have the same right. Moreover, no agent, representative, or employee of KSB Services, Inc., except in a specific written contract of employment signed on behalf of the organization by its President, has the

power to alter or vary the voluntary nature of the employment relationship.
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

____________________________________                              _______________
APPLICANT SIGNATURE                                                                                        TODAY'S  DATE