APPLICATION FOR EMPLOYMENT



Full Name__________________________________________________________________________
Street Address_____________________________________________________Apt#______________
City_______________________State_______Zip Code______________
How long at this address?_________________ If less than two years, previous address:
Street Address_____________________________________________________Apt#______________
City_______________________State_______Zip Code______________
Home Phone Number_____________________Cell Phone Number____________________________
E-mail Address____________________________________Best way to reach you________________
Social Security Number_______-______-____________
Age_______Birth Date__________________
If under 18, can you provide a work permit?     Y     N

Type of employment desired:     FULL TIME     PART TIME     TEMPORARY     SEASONAL
Position desired:     FRONT/CASHIER     COOK     DRIVER
Date You Can Start_________________________Are you employed now?     Y     N
If so, may we contact your present employer?     Y     N

AVAILABILITY
Total hours available per week_________
Mon Tue Wed Thu Fri Sat Sun
From              
To              





Are you legally able to be employed in the US?     Y     N

EDUCATION
School most recently attended?_________________________________________Year_____________
Location___________________________________Phone Number____________________________
Last grade completed_______________________________Graduated?     Y     N
Sports/Extra-curricular Activities________________________________________________________

EMPLOYMENT
Name and Address of Employer Salary Position Reason for Leaving
From
To
       
From
To
       
From
To
       
From
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REFERENCES
1)Name____________________________________Years Known________________
Occupation__________________________________Phone Number______________
2)Name____________________________________Years Known________________
Occupation__________________________________Phone Number______________
3)Name____________________________________Years Known________________
Occupation__________________________________Phone Number______________
Are you capable of performing the essential functions of the job for which you have
applied, with/without reasonable accommodation?     Y     N

Have you ever been convicted of violating any law (except minor traffic violations)?     Y     N
If yes, please attach a summary of details. Disclosure of a criminal record does not automatically
disqualify you from employment consideration. Date of offense, seriousness and nature of the violation,
rehabilitation and position applied for will be considered.

Person to contact in case of Emergency____________________Relation_______________________
Address____________________________________________Home Phone_____________________
Work Phone_________________________Cell Phone/Pager_________________________________


AUTHORIZATION

    "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements contained herein may result in my dismissal. I give my permission for the references and employers listed above to give you any and all information concerning my previous employers and any pertinent information they may have,personal or otherwise, and release the company from all liability for and damage that may result from utilization of such information.


    I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by and authorized by a company representative.


    This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."


Date________________________Signature_______________________________________________


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