Application for Employment

Date ______________

Last name ________________________ First name ________________ Middle name________

Local Address ___________________________City___________________________________

Permanent Address:___________________City _________________ State ____ ZIP _______

Telephone ___________________________ Cell ___________________________

Position applied for ______________________________________________________________

What hours are you available? ______________

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From:
To:

Would you have any problems serving minorities(racial, ethnic, sexual orientation, mentally ill?)

_____________________________________________________________________________

Employment History (Start with most recent employer)

1.Company Name ______________________________________________________________

Address ____________________________________ Telephone _________________________

Date Started ___________ Starting Wage ____________ Starting Position ________________

Date Ended _____________ Ending Wage ____________ Ending Position ________________

Name of Supervisor ____________________________________

May we contact? q Yes q No Reason for leaving _________________________________

Responsibilities _______________________________________________________________

_____________________________________________________________________________

2.Company Name ______________________________________________________________

Address ____________________________________ Telephone _________________________

Date Started ___________ Starting Wage ____________ Starting Position ________________

Date Ended _____________ Ending Wage ____________ Ending Position ________________

Name of Supervisor ____________________________________

May we contact? q Yes q No Reason for leaving _________________________________

Responsibilities _______________________________________________________________

_____________________________________________________________________________

3.Company Name ______________________________________________________________

Address ____________________________________ Telephone _________________________

Date Started ___________ Starting Wage ____________ Starting Position ________________

Date Ended _____________ Ending Wage ____________ Ending Position ________________

Name of Supervisor _________________________________ ___

May we contact? q Yes q No Reason for leaving _________________________________

Responsibilities _______________________________________________________________

_____________________________________________________________________________

Do you have food service, retail experience or coffee bar experience not listed under recent employment? List what types and number of months/years.

______________________________________________________________________________

_________________________________________________________________________________

What experience do you have with cash registers and or computers? ________________________________________ ________________________________________

Anything else you want to tell us about yourself? ________________________________________ ________________________________________________________________________________

______________________________________________________________________________

Education School Name and Location Year Major Degree

High School ________________________________________ ______ ______ ______

College ___________________________________________ ______ ______ ______

Other Training ______________________________________ ______ ______ ______

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) q Yes q No

Please list 3 work references with telephone, do not list FRIENDS OR RELATIVES.

NAME	PHONE #	TITLE	YEARS KNOW
1.
2.
3.

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.

Signature_______________________________________________ Date _________________

Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

Thank you, Barb and Carla.