apply

Today's Date

First Name

Last Name

Date of Birth

Social Security Number

Street Address

City

State

ZIP

Phone Number

Best Time To Call

Work Availability

Are you at least 18 years of age?

YES NO

Do you have a valid driver's license?

YES NO

Emergency Contact Information (Name, complete address & phone number)

How did you hear about us?

If hired, can you provide proof of citizenship or employment authorization?

Yes NO

If "No", please explain.

Have you ever been convicted of a felony?

YES NO

If "YES", please explain (A conviction is not an automatic bar from employment)

High School Name, City, State, Years Attended, Degree/Certificate

Did you graduate?

Nursing / Tech School Name, City, State, Years Attended, Degree/Certificate

Did you graduate?

College Name, City, State, Years Attended, Degree/Certificate

Did you graduate?

Post-College Name, City, State, Years Attended, Degree/Certificate

Did you graduate?

Other Training Name, City, State, Years Attended, Degree/Certificate

Did you graduate?

Professional Affiliations / Organizations (Name / Type Member Number & Expiration Date, List All)

1. Past Employer Name

Address, City, State, Zip

Supervisor Name

Contact Phone Number

Salary

Dates To and From

2. Past Employer Name

Address, City, State, Zip

Supervisor Name

Contact Phone Number

Salary

Dates To and From

3. Past Employer Name

Address, City, State, Zip

Supervisor Name

Contact Phone Number

Salary

Dates To and From

Please Read Carefully:
I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal. I authorize any insurance company, employer, educational institution, law enforcement organization, state or federal government agency, information service bureau, medical facility or practitioner, and any other person or organizations listed in this application to release information regarding my character, performance, qualifications, background, reasons for termination of past employment, and eligibility for rehire to Delta Maids or Delta Maids. I also understand that as a condition of my employment I will complete a background check including, but not limited to, criminal records, social security number verification, and driving record. I also authorize the release of my driving history and criminal records, and understand that it may contain information about my background, mode of living, character, and personal reputation. I understand that a criminal conviction is not an automatic bar from employment and will be reviewed for job related impact. I authorize you to request and receive such information, and release you and all parties involved in providing such information from any responsibility or liability. I understand that the decision to hire is solely that of Delta Maids or Delta Maids. As a condition of my employment with the Company, I agree that all information which I receive in the course of my employment relating in any manner to, among other things, the business activities, customers, production processes, financial affairs, programs, concepts or designs of Delta Maids or Delta Maids are to be treated by me as trade secrets and kept in confidence, not to be disclosed to any unauthorized person either during or after my employment, or used by me in any manner adverse to the interest of Delta Maids or Delta Maids. In addition, I may be required to sign a separate Invention and Confidentiality Agreement. In consideration for my employment by your Company, I agree to conform to the rules and regulations of the Company and acknowledge that these rules and regulations may be changed, interpreted, suspended, withdrawn, or added to by your Company at any time, at the Company's sole option and without any prior notice to me. I further acknowledge that my employment is at-will and may be terminated, and any offer of employment, if such is made, or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of the Company or myself. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Delta Maids or Delta Maids and myself for either employment or for providing of any benefit. If my services terminate after accepting employment, I understand that Delta Maids or Delta Maids, or any of its affiliates may supply, in confidence, my employment record to any prospective employer, with no liability to the Company or its staff. I acknowledge that I have been advised that this application will remain active for no more that sixty (60) days from the date it was made.

apply

QUICK LINKS