| Date of Application: |
|
| Position(s) Applied for: |
|
| Rate of Pay Expected ($): |
|
| Referral Source: |
Advertisement
Friend
Relative
Employee
Employment Agency |
| Personal Information |
| Name (Last/First/Middle): |
|
| Street Address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Phone Number: |
|
| Email: |
|
| If you are under 18 years of age, can you provide required proof of your eligibility to work? |
|
| Have you ever been employed with us before?:
|
| If yes to the above, give date:
|
| Are you available to work: |
Full Time
Part Time
Temporary |
| Are you available to work: |
6am - 4:30pm
4:30pm - 3am
Weekend shift 6am - 6pm (Friday, Saturday, and Sunday) |
| Are you legally eligible for employment in the USA?:
|
| On what date would you be available for work:
|
| Were you ever convicted of a crime?:
|
| If yes to the above, when, where and nature of offense?:
|
| Are there any felony charges pending against you?:
|
| Person to notify in case of emergency:
|
| Emergency Contact's Phone:
|
| Employment Experience |
| Summarize special skills and qualifications acquired from employment, education or training: |
|
| Starting with your present or last job include any job related military service assignments and volunteer activities (excluding organizations, which indicate the race, color, religion, national origin or ancestry of its members.) |
| Employer: |
|
| Date Employed: |
From To
|
| Work Performed: |
|
| Address: |
|
| Telephone Number(s): |
|
| Job Title/Supervisor: |
|
| Reason for Leaving |
|
| |
| Employer: |
|
| Date Employed: |
From
To
|
| Work Performed: |
|
| Address: |
|
| Telephone Number(s): |
|
| Job Title/Supervisor: |
|
| Reason for Leaving: |
|
| |
| Employer: |
|
| Date Employed: |
From
To
|
| Work Performed: |
|
| Address: |
|
| Telephone Number(s): |
|
| Job Title/Supervisor: |
|
| Reason for Leaving: |
|
| In compliance with Federal and State Equal Employment Opportunity Laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, handicap, height, weight, marital status, veteran status, or any other legally protected status. |
|
