Employment Application

Personal Information

Name *
Prefix
First *
Last *
Suffix
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Phone Number *

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###		-
####
Email
If you are under 18 years of age, enter date of birth

MM		/
DD		/
YYYY
Are you eligible to work in the United States? *
 Yes 
 No 
Lifting of objects up to 35 lbs. may be required in the course of your employment. Are you able to do so? *
 Yes 
 No 
 Other 
Constant physical activity is necessary. Are you able to be physically active the entire shift? *
 Yes 
 No 
 Other 
Do you have reliable transportation to report to work as scheduled? *
 Yes 
 No 

POSITION/AVAILABILITY:

Willing to work at... *
 Oxford 
 Tiffin 
 Coralville 
 Gilman 
Position applying for *
 Kitchen 
 Register 
 Manager 
Days Available *
 Monday 
 Tuesday 
 Wednesday 
 Thursday 
 Friday 
 Saturday 
 Sunday 
 Any 
Hours Available *
 AM 
 Full-Time 
 Day 
 Part-Time 
 PM 
 Temporary 
For specific Day/Hour availability, please enter information below.
What date are you available to start work? *

MM		/
DD		/
YYYY
Extracurricular Activities *
Enter sports involved in, hobbies, etc.
Salary Expected *

EDUCATION:

Select the highest level of education that applies to you. *
Name Of School - Degree/Diploma - Graduation Date *
Skills and Qualifications: Licenses, Skills, Training, Awards

EMPLOYMENT HISTORY:

Most Recent or Current Position:
Employer:
Supervisor:
Phone Number

###		-
###		-
####
Position Title:
Ending Salary
Start Date

MM		/
DD		/
YYYY
End Date

MM		/
DD		/
YYYY
Responsibilities:
Reason for Leaving:

Previous Position
Employer:
Supervisor:
Phone Number

###		-
###		-
####
Position Title:
Ending Salary
Start Date

MM		/
DD		/
YYYY
End Date

MM		/
DD		/
YYYY
Responsibilities:
Reason for Leaving:

May We Contact Your Present Employer? *
 Yes 
 No 
Were you ever discharged by any company? *
 Yes 
 No 
Have you ever been convicted of a crime other than a minor traffic violation? (Note: You are not obligated to discuss sealed or expunged records of conviction or arrest nor will such information be asked of you or considered in employment decisions.) *
 Yes 
 No 

Professional References

Do not use friends or family members.
Reference #1 *
Prefix
First *
Last *
Suffix
Phone Number *

###		-
###		-
####
Relationship *

Reference #2 *
Prefix
First *
Last *
Suffix
Phone Number *

###		-
###		-
####
Relationship *

Reference #3 *
Prefix
First *
Last *
Suffix
Phone Number *

###		-
###		-
####
Relationship *
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