What is your full name?

Name

Mailing address

                       Town:

                        State:

                           Zip:

        E-mail address:

            Home phone:

            Work phone:

  Social Security No.:

May we contact you at work?

Yes No

What is your age? 

If you are over 18, can you provide proof of age?

Yes No

If you are under 18, can you provide a work permit?

Yes No

Have you ever applied with us before?

Yes No

Have you ever worked for us before?

Yes No

List any employees that work for us that may be friends or relatives to you, and give their relationship:

What position are you applying for?

Kitchen Wait staff either of them

What date are you available for employment?

-- mm/dd/yy

How long do you plan to work?

Temporary Summer Less than 1 year More than 1 year

How did you become aware of this opening?

Stopped in Employee Ad / paper Sign in store Other

In the space below, please provide me with the days you can work, and the hours you can work for each day. (example: Mon. 2pm to close, etc.)

Can you work a flexible schedule?

Yes No

Do you have access to transportation for work?

Yes No

What is the minimum number of hour per week you would consider acceptable?

10 hours 15 hours 20 hours 30 hours 40 hours

How many days were you absent from work during the past 12 months?

0-6 days 6-10 days 10-15 days 15+ days

Below, tell us why you would consider employment at this restaurant:

What are the two (2) most important factors to you when choosing a job?

Are you currently employed?

Yes No

Do you plan to continue your current job if you work for us?

Yes No N/A

Why have you left, or are planning to leave your present job?

In the past 5 years, how many different employers have you worked for?

Have you ever worked in a restaurant before?

Yes No

Have you been asked to resign or been terminated from a job in the past five years?

Yes No

If you responded yes to the previous question, explain below. (response will not necessarily disqualify you, each case is considered individually)

Are you currently a student, or planning to go to school within the next 12 months?

Yes No

If you responded yes to the previous question, what impact does going to school have on your ability to work? explain below:

Do you have any commitments, i.e. vacation plans scheduled activities, etc. that could affect your availability work work if offered employment?

Yes No

If yes to the last question, please note time and length of unavailability below:

May we contact your present employer?

Yes No Not presently employed

In the space below, please give the company name and address of your last or present employer:

Enter dates employed i.e. "from / to" month/day:

What was your position or title?

Company telephone number:

Starting rate of pay:

What was your last rate of pay?

What was your supervisor's name and title?

Reason for leaving?

What did you like most about the job?

What did you like least about the job?

What is the company name of the employer before the previous one?

Dates employed? i.e. from/to, month/day:

What was your tile?

Company telephone:

Starting rate of pay?

Ending rate of pay?

Supervisor's name and title?

Reason for leaving?

What did you like most about the job?

What did you like least about the job?

Please provide the name and location of the high school you attended:

Dates attended. i.e. From/to, month/year:

Did you graduate?

Yes No GED

Name and location of college or university:

Dates attended, i.e. from/to month/year:

What was your subject or degree?

Are you currently enrolled in a course of study?

Yes No

If yes to the previous question, what and where?

Are you legally eligible for employment in the USA?

Yes No

Have you been convicted of a felony within the last 10 years? (note: a conviction record will not necessarily disqualify you.)

Yes No

If yes to the previous question, please explain below:

In the space below. please list three personal references. Give full name, occupation, company/school, address, and phone number. These individuals should not be related to you, and are in a position to evaluate your suitability for employment. (i.e. former worker, teacher, guidance counselor, etc.)

Please put your full name, as you would sign it, to the fact that the above information is true and complete, to the best of your knowledge.

Date of this application:

-- mm/dd/yy

Congratulations, you have finished this form. Please "single click" the submit form button below. Please call 802-485-6363 to follow up after submitting. Good luck and thank you!