Application


	*Personal Information*


	Last Name, First Name, M.I.


	Street Address


	City


		Phone


	State


	Cell Phone


	Zip


	E-Mail


	Have you been convicted of a felony or misdemeanor in the last five years? Select One

YES

If Yes, List convictions in the space below. A conviction will not necessarily disqualify you for employment


	Are you 18 years of age or older ?

YES


	If under 18 years of age, proof of age must be provided before hiring.


		Check if you have suffered any of the following:

	*Immigration Information*


Heart Trouble
Back Injury


Epilepsy
Diabetes


Rupture/Hernia
High or Low Blood Pressure


	Is your citizenship or immigration status such that you can lawfully work in the USA ?

YES

If hired, employment may be dependant upon proof of citizenship and presentation and satisfactory identifying documents, as required by Immigration and Naturalization Service laws.


	*Employment History*


	Supervisor’s Name & Phone
Employer Name and Address
		Reason for Leaving

From:

To:


	Position:


	Salary:


	Supervisor’s Name & Phone
Employer Name and Address
		Reason for Leaving

From:

To:


	Position:


	Salary:


	*Employment Desired*

Full Time

Part Time

Temporary

Summer


	Date Available


	Position Desired


	Pay Expected


	Days and Hours Available to Work

Day

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

From:

To:


	*Applicant's Statement*

I hereby authorize Cotton Creek Car Wash to make an independent investigation of my background, credit references, motor vehicle record, past employment and education, including those maintained by both public and private retail credit reporting and security service organizations and all public records. In compliance with Fair Credit Reporting Act, you may request a copy of the report from the independent agency or service by mailing a written request within a reasonable period of time.
I release Cotton Creek Car Wash from any liability claims or lawsuits regarding information obtained from any and all of the aforementioned resources used by Cotton Creek Car Wash.


	Applicant’s Initials


	Date

!!! IMPORTANT !!! PLEASE READ CAREFULLY

You must click on the submit button.

Once you do, an e-mail will be generated with your default e-mail program. You then need to send that e-mail. The correct e-mail address should already be there, however if not, please send to george@cottoncreekcarwash.com