Registration: Jack's Maintenance Shiftboard

We are committed to a policy of Equal Employment Opportunity and will not discriminate in employment opportunities or practices on the basis of race, color, citizenship status, religion, creed, gender, sex, sexual orientation, national origin, ancestry, age, physical or mental disability, marital status, veteran status, political beliefs or affiliations, income level or source of income, arrest record or conviction record, less-than-honorable discharge, physical appearance, student status or any other characteristic provided by law.

* required field

If driving is a requirement of the job for which you are applying, do you have a current valid driver's license?
 Yes  No

If driving is a requirement of the job for which you are applying, continued employment is contingent upon your maintaining a current driver's license. An acceptable driving record, as determined by employer's insurance company, may also be required.

Have you ever been convicted of a crime?
 Yes  No

A conviction record will not necessarily be a bar to employment.

Please refer to the job description(s) on the first page of the Application for Employment. Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation?
Refer to: Application for Employment
 Yes  No

Reasonable accommodation available to qualified applicants.

Have you ever been counseled or disciplined for being late or absent from work or school?
 Yes  No
Have you ever applied or worked for Jack's Maintenance Service in the past?
 Yes  No
If yes, when?
If hired, what is the soonest you would be able to start working?
Please indicate any language(s) you are comfortable communicating in.
If other, please list
What is the farthest you would be able to commute to work? (Indicate in either time or miles)

Please indicate any experience in janitorial work, carpet/upholstery cleaning, floor scrubbing/buffing, window cleaning, etc. List dates, places worked and any equipment experience you have:
Choose "Any Available" for fastest consideration
Any Available
Full-Time Work
Part-Time Work
1st shift
2nd shift
3rd shift
Even if not your preference, check if you are available and able to work:
Any Available
Full-Time Work
Part-Time Work
1st shift
2nd shift
3rd shift

EMPLOYMENT HISTORY - Please list your employer(s) beginning with most recent (continue on next page if necessary)
1 - Company
1 - Start Date
1 - End Date
1 - Position You Held
1 - Ending Wage
1 - Why You Left
1 - Job Duties

2 - Company
2 - Start Date
2 - End Date
2 - Position You Held
2 - Ending Wage
2 - Why You Left
2 - Job Duties
3- Company
3 - Start Date
3 - End Date
3 - Postion You Held
3 - Ending Wage
3 - Why You Left
3 - Job Duties

4 - Company
4 - Start Date
4 - End Date
4 - Position You Held
4 - Ending Wage
4 - Why You Left
4 - Job Duties

PERSONAL REFERENCES - Please list (2) references of people not related to you
First Reference Name
First Reference Relationship
First Reference Phone
First Reference Address
First Reference City
How Long Known
Second Reference Name
Second Reference Relationship
Second Reference Phone
Second Reference Address
Second Reference City
How Long Known


There are no right or wrong answers. Simply explain what YOU think you offer in terms of skill, work ethic, qualifications or anything else that would make you an asset to the team.

Tell us what you think would make you a great employee at Jack's Maintenance Service


By submitting this application, I certify that all of the foregoing information is a complete and accurate statement of the facts and understand and agree that any misrepresentation, omission or falsification will constitute grounds for disqualification from consideration and/or from active employment with the company regardless of when such information is discovered. Any offer of employment will be contingent on successfully meeting security requirements of Jack's Maintenance Service, Inc. and/or customer account(s) to which you are being considered for placement. Such requirements may include passing a criminal background check, driver's record verification and/or a drug screening.


Equal Opportunity/Affirmative Action Employer

* I acknowledge and accept Applicant's Statement
* Application Date

Voluntary Self- Identification

Jack's Maintenance Service is an equal opportunity/affirmative action employer. Providing this information is voluntary and allows us to meet government reporting requirements and evaluate the effectiveness of our recruiting efforts. This information will be kept confidential and when reported, will not identify any specific individual. Refusal to provide this information will not subject you to any adverse treatment in any employment process. Jack's Maintenance Service policies and applicable law prohibit discrimination based on this information.

I decline to answer.
Veteran Status.
If other, please specify
Race - Please check one or more
Asian/Pacific Islander
Hispanic or Latino
Black/Africa American (Not Hispanic)
Indian/Alaskan Native
White (Not Hispanic)
If other, please specify race.
Date of Birth (Month/Date/Year). If you are hired, or become a finalist for hire in select positions, we will require your date of birth. This information is used for the sole purpose of a background check.
Social Security Number. If you are hired, or become a finalist for hire in select positions, we will require your social security number. This information is used for the sole purpose of a background check. You may also choose not to provide your SSN at this time.

Do you have a disability? Jack's Maintenance Service considers a person with a disability anyone who meets the definition under either the Americans with Disabilities Act or the Wisconsin Fair Employment Act. If you have questions please contact our Human Resources Department.
 Yes  No
Do you need accommodation in the hiring/examination process?
 Yes  No
If yes, please describe accommodation requested (e.g. extended time, reader, alternative format, etc.

You will be required to provide written verification from a doctor or other authorized person confirming your disability and indicating a need for reasonable accommodation.

How did you hear about this job opening?
Company website (
Print advertising (flyer or newspaper etc.)
Other website
Referred by friend or family or other employee etc.
Job agency
If you heard about this job opening via other, please specify.


I authorize Jack's Maintenance Service, Inc. to verify the information within this application, including any attachment(s) and/or inclusion(s), and to investigate my personal history including but not limited to my criminal and/or driving records. I understand that Jack's Maintenance Service, Inc. may request information from federal, state, county and/or local agencies that maintain such records. I understand that, within a reasonable time, I may make a written request for information concerning such investigation. I authorize the companies, schools and/or persons listed on this application to disclose information requested by Jack's Maintenance Service, Inc. regarding my employment, character and/or qualifications. I hereby release and hold harmless Jack's Maintenance Service, Inc., all affiliated persons and entities, as well as any person, company and/or institution that provides Jack's Maintenance Service, Inc. with any lawful information about me, from any liability whatsoever resulting from such lawful inquiry, investigation or communication.

Full Name
LIST ANY OTHER NAME(S) YOU HAVE USED (including maiden name if applicable)
Current Street Address
Current City
Drivers License Number
Driver's License State
Drivers License Expiration Date
Date of birth and social security number is requested solely for the purpose of obtaining accurate records during the investigative process and is not used for any other purpose.

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We appreciate your time and interest




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