First Name:
Last Name:
Middle Initial
Email Address:
Home Address:
City, State, Zip Code:
Home Number:
Work Number:
Cell Number:
Social Security Number:
Are you at least 21 years of age?
Are you eligible to work in this country?
Please describe your skills or experience in the position you select.
Days and times you are available: (Please enter when you are available on each day)
Do you have a valid Maryland drivers license?
Do you have a reliable, insured car?
Can you type?
How many words can you type per minute?
Are you computer literate?
Are you Bilingual?
Can you comfortably handle walking 2 dogs at a time?
Can you comfortably handle a dog up to 100 pounds?
Are you able to give a pill to a cat?
Are you able to give insulin injections?(pets)
Is there any type of pet you prefer not to service? Why?
What is your motivation for seeking out employment with us?
Please list any education or volunteer work that you feel is relevant.
Highest Level of Education:
School Name and Address:
Graduated:
Year Graduated:
Please describe yourself, describing any special skills as well as any faults.
Professional Reference 2:
Professional Reference 3:
Please provide us with 3 personal references. Personal Reference 1: (Name, relationship & telephone number).
Personal Reference 2:
Personal Reference 3:
Have You Ever Been Convicted of a Crime?:
If Yes, explain number of conviction(s), nature of offense(s) leading to convictions(s), how recently such offense(s)
was/were committed, and sentence(s) imposed.
I confirm that the information provided above is accurate and true to the best of my knowledge. I warrant that
I am not interviewing with Mason-Dixon Concierge, LLC to gain knowledge of their concierge business in order to start my own
business.
I hereby authorize any person, educational institution, medical facility, company or law enforcement agency to
disclosed any information they may have regarding my qualifications and fitness for employment.
