Date of Application_________________
PERSONAL INFORMATION (Please Block Print Legibly in black ink)
Name (Last) (Suffix) (First) (Middle) ________________________________________________
Address, City, State, Zip ___________________________________________________________
Phone________________ Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
E-mail Address: _________________________________________________________________
Are you at least 18 years old?
Yes No
Are you legally authorized for employment in the United States?
Yes No
If hired, will you be able to provide proof of legal eligibility to work?
Yes No
Have you ever worked for our company before?
Yes No
If yes, when and where? _____________________________________________________
What language(s) other than English do you speak? __________________________________
Are you willing to work where there is no smoking at any time?
Yes No
EMPLOYMENT DESIRED
What position(s) are you applying for? _____________________________________________
When are you available to start? ________________Maximum Hours/Week? _____________
What do you hope to earn? _______________________________________________________
What type of job(s) are you applying for?
Full Time Part Time Seasonal Temporary Contract
How did you hear we were hiring?
Job Line Walk In Job Fair Newspaper/Ad Employee Referral Other _________
Location Preference(s)? __________________________________________________________
Hours Available
Sunday:
From_____________ To_______________
Monday:
From_____________ To_______________
Tuesday:
From_____________ To_______________
Wednesday:
From_____________ To_______________
Thursday:
From_____________ To_______________
Friday:
From_____________ To_______________
Saturday:
From_____________ To_______________
EDUCATION
High School
Name Address Years Degree
______________________________________________________________________________________________________________________________________________________________
Community/Tech
Name Address Years Degree
______________________________________________________________________________________________________________________________________________________________
College
Name Address Years Degree
______________________________________________________________________________________________________________________________________________________________
Graduate
Name Address Years Degree
______________________________________________________________________________________________________________________________________________________________
Job Training
Company/School Address Years Certificate/Skill
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EMPLOYMENT HISTORY (Please complete and do not indicate, “Refer to Resume”. List all current and former employment for the last 10 years, beginning with the most recent.)
Employer ______________________________________________________________________
Dates of employment: From (month/year) ______________To (month/year) ______________
Address, City, State, Zip Code _______________________________________________________________________________
Telephone number ________________ Starting Salary ________Ending Salary ________
Position ________________________________ Supervisor’s Name_____________________
Work Duties ______________________________________________________________________________________________________________________________________________________________
Reason for leaving ______________________________________________________________________________________________________________________________________________________________
Employer ______________________________________________________________________
Dates of employment: From (month/year) ______________To (month/year) ______________
Address, City, State, Zip Code _______________________________________________________________________________
Telephone number ________________ Starting Salary ________Ending Salary ________
Position ________________________________ Supervisor’s Name_____________________
Work Duties ______________________________________________________________________________________________________________________________________________________________
Reason for leaving ______________________________________________________________________________________________________________________________________________________________
Employer ______________________________________________________________________
Dates of employment: From (month/year) ______________To (month/year) ______________
Address, City, State, Zip Code _______________________________________________________________________________
Telephone number ________________ Starting Salary ________Ending Salary ________
Position ________________________________ Supervisor’s Name_____________________
Work Duties ______________________________________________________________________________________________________________________________________________________________
Reason for leaving ______________________________________________________________________________________________________________________________________________________________
May we contact your current employer?
Yes No
May we contact your previous employer(s)?
Yes No
PERIODS OF UNEMPLOYMENT (Please account for all periods of unemployment)
Dates: From month/year _______________ to month/year ____________________
Explanation_____________________________________________________________________
MILITARY EXPERIENCE
Position ________________________________ Start Date _________ End Date ________
Branch, Location_________________________________________________________________
Supervisor’s Name _____________________________________
Job Duties: _____________________________________________________________________
_______________________________________________________________________________
VOLUNTEER EXPERIENCE
Organization ____________________________ Start Date _________ End Date ________
Telephone _____________________ Supervisor’s Name ______________________________
Position __________________________________
Job Duties: _____________________________________________________________________
_______________________________________________________________________________
REFERENCES (Please provide 3 professional and work references)
Name ____________________________________ Telephone Number __________________
Company ______________________________________ Position _________________________
Address, City, State _____________________________________________________________
Name ____________________________________ Telephone Number __________________
Company ______________________________________ Position _________________________
Address, City, State _____________________________________________________________
Name ____________________________________ Telephone Number __________________
Company ______________________________________ Position _________________________
Address, City, State _____________________________________________________________
PREVIOUS CONVICTION INFORMATION
The existence of a conviction will not automatically disqualify you as a job applicant. Do not answer, “yes” if the conviction has been expunged, annulled, sealed, statutorily eradicated, pardoned, dismissed upon condition of probation or is only a minor traffic violation.
Have you been convicted of a crime other than a minor traffic violation? Yes No
If yes, please explain: ______________________________________________________________________________________________________________________________________________________________
The Secretary of Health & Human Services has determined that certain diseases, including Hepatitis A, Typhoid Fever (Salmonella Typhi), Shigellosis (Shigella App.) and E. Coli (Escherichia Coli 0157H7) may prevent you from serving food or handling food equipment in a sanitary or healthy fashion. An essential function of some jobs involve handling and serving food, food service and equipment and utensils in a sanitary and healthy fashion. Are you able to perform the essential functions of this job with or without a reasonable accommodation?
Yes No If no, explain: ______________________________________________
I certify that I have read and fully completed both sides of this application and that the information contained herein is correct to the best of my knowledge. I understand that any omission or false information is grounds for dismissal. I authorize the references listed on this application to give you any and all information concerning my previous employment and pertinent information they may have, personal and otherwise. I understand that as a part of the procedure for my employment application an investigative consumer report may be made concerning my character, general reputation, personal characteristics and mode of living.
Employees are “at will”, which means that he/she can terminate the employment at any time, for any or no reason. This company reserves the right to change and/or terminate employment, compensation and benefits with or without notice or cause at any time.
You understand that a job offer is conditional upon passing a drug test and a criminal background check.
Signature ________________________________________________ Date______________
