____________________Employment Application____________________

Please fax or mail the completed application to:

516.795.2990

Annie Shines Cleaning Service

PO Box 1871

N. Massapequa, NY 11758

_____________________________________________________________________________________

Personal Information

Full Name ______________________________________________________________________________

Residence Address ______________________________________________________________________

City ______________________________________

State _____________________________________

Zip Code __________________________________

Home Phone ________________________________

Alternate Phone ___________________________

E-mail ____________________________________

Do you have a legal right to work in the U.S.? (if yes, appropriate documentation

required) YES or NO

Date you are available to begin work _____________________________

For which position are you applying ______________________________

Job Title

Number of hours per week (full time = 40 hrs./week) ______________

Salary rate expected ______________________

Are you under 18 years of age? YES or NO

Were you referred for employment by an Annie Shines employee? YES or NO

If yes, employee's name __________________________________________

Have you ever been employed by this company? YES or NO

If yes, when?______________________________

High School or equivalent institution

Name____________________________________________________________________________________

Location _______________________________________________________________________________

Diploma or GED? YES or NO

Advanced Education - College, University, or Vocational/Technical

(Applicants may be asked to furnish transcripts of school or college work where appropriate.)

Name of Institution ___________________________________________________________________

Major _________________________________________________________________________________

Degree Received _______________________________________________________________________

Work History

Give employment history as completely as possible, starting with your present or most recent employer. For any unemployed periods, show activities, dates and location. Include U.S. Military Service. Note: Our employment process includes VERIFICATION of employment history. Please indicate any employers we should not contact.

Current or Most Recent Position

Employer _______________________________________________________________________________

Position Held __________________________________________________________________________

Business Address _______________________________________________________________________

City/State/Zip _________________________________________________________________________

Business Phone ________________________________________

May we contact? YES or NO

Supervisor's Name _____________________________________

Supervisor's Title ____________________________________

Supervisor's Phone ____________________________________

Salary (base pay): Hourly - Weekly - Monthly - Annually

Beginning Salary ______________________________________

Ending Salary _________________________________________

Dates Employed (Month/Year)

From __________________________________________________

To ____________________________________________________

Reason for Leaving _____________________________________________________________________

Your Responsibilities: _________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

First Previous Position

Employer _______________________________________________________________________________

Position Held __________________________________________________________________________

Business Address _______________________________________________________________________

City/State/Zip _________________________________________________________________________

Business Phone ________________________________________

May we contact? YES or NO

Supervisor's Name _____________________________________

Supervisor's Title ____________________________________

Supervisor's Phone ____________________________________

Salary (base pay): Hourly - Weekly - Monthly - Annually

Beginning Salary ______________________________________

Ending Salary _________________________________________

Dates Employed (Month/Year)

From __________________________________________________

To ____________________________________________________

Reason for Leaving _____________________________________________________________________

Your Responsibilities: _________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Second Previous Position

Employer _______________________________________________________________________________

Position Held __________________________________________________________________________

Business Address _______________________________________________________________________

City/State/Zip _________________________________________________________________________

Business Phone ________________________________________

May we contact? YES or NO

Supervisor's Name _____________________________________

Supervisor's Title ____________________________________

Supervisor's Phone ____________________________________

Salary (base pay): Hourly - Weekly - Monthly - Annually

Beginning Salary ______________________________________

Ending Salary _________________________________________

Dates Employed (Month/Year)

From __________________________________________________

To ____________________________________________________

Reason for Leaving _____________________________________________________________________

Your Responsibilities: _________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

General Information

Have you ever been convicted of a criminal offense involving dishonesty or breach of trust? YES or NO

If yes, give offense, date and disposition of case:*

________________________________________________________________________________________

________________________________________________________________________________________

*You are not required to disclose any arrest or detention that did not result in conviction; any conviction for which the record has been judicially expunged, sealed or statutorily eradicated; any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed; or any arrest for which a pretrial diversion program has been successfully completed. A conviction will not necessarily disqualify you from employment.

Have you ever had a fidelity bond canceled or refused? YES or NO

If yes, please explain _________________________________________________________________

________________________________________________________________________________________

Certification

The facts set forth in my application for employment are true and complete. I understand that if employed, and false statement on this application may result in my dismissal. You are hereby authorized to make any investigation of my personal history. I agree to notify Annie Shines immediately if I should be convicted of any crime involving dishonesty or breach of trust while my application is pending or after I am hired.

I hereby agree that this employment application does not constitute an offer of employment. I further agree and understand that if I am hired by Annie Shines, my employment will be on an "at will" basis, and can be terminated by either me or Annie Shines at any time for any reason with or without cause.

This information will be kept confidential except that (1) Supervisors and Managers may be informed regarding work restrictions or accommodations; (2) First Aid and safety personnel may be advised to the extent appropriate; and (3) Government Officials investigating compliance with the Rehabilitation Act or the Vietnam Era Veterans Readjustment Assistance Act may have access to the information.

By submitting this application, you agree to the waiver that follows:

Waiver: I understand that by sending this form my personal information may not be secure and I release Annie Shines Cleaning Services and all its officials, employees, affiliates, subsidiaries, vendors, and assignees from any liability and/or loss that arises from using this form.

SIGNATURE OF APPLICANT X_______________________________________________ Date __________