PERSONAL INFORMATION

First Name* MI Last Name*
Permanent Address*
City* State* Zip Code*
Telephone* Email Address*

Are you legally eligible to work in the United States?* Yes No

State age if under 18:

Have you ever been convicted of a felony?* Yes No

If yes, please explain:


Is there anything that would prevent you from performing the functions of this position with or without reasonable accommodations?* Yes No

If yes, please explain:


AVAILABILITY

Days Available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Hours per week desired:

What date are you available to start working? (mm/dd/yyyy)

Additional comments regarding availability and schedule limitations:


SKILLS

Check those that apply:
Basic computer operation
Cash register operation
Fluency in foreign language

Are there any other experiences, skills, or abilities that you feel qualify you to work here?


EDUCATION

I am currently enrolled in:
High School
College
Other
None

High School* (name and location):
Graduated: (mm/yyyy)


College (name and location):
Graduated: (mm/yyyy)


Other (name and location):
Graduated: (mm/yyyy)


Additional comments regarding education:

EMPLOYMENT HISTORY

Company 1 (name and location):
Job Description:
Supervisor:
Supervisor's Phone:
Permission to contact? yes    no
Start: (mm/yyyy) End:
Reason for leaving:
Company 2 (name and location):
Job Description:
Supervisor:
Supervisor's Phone:
Permission to contact? yes    no
Start: (mm/yyyy) End:
Reason for leaving:


Company 3 (name and location):
Job Description:
Supervisor:
Supervisor's Phone:
Permission to contact? yes    no
Start: (mm/yyyy) End:
Reason for leaving:


Company 4 (name and location):
Job Description:
Supervisor:
Supervisor's Phone:
Permission to contact? yes    no
Start: (mm/yyyy) End:
Reason for leaving:


REFERENCES

Name Relationship Telephone
Name Relationship Telephone
Name Relationship Telephone

ADDITIONAL INFORMATION

Salary expected:

This company is an equal opportunity employer and will not discriminate, or tolerate discrimination, against any employee or applicant in any manner prohibited by law.

I certify that the information on this application is true and complete to the best of my knowledge. I understand that any false information on this application shall be grounds for dismissal.

I authorize investigation of all information contained on this application. I give permission to the references and employers listed to provide any information they may have, personal or otherwise, and release all parties from any liability or damages that may result from such information.

I understand that no representative of the company has the authority to enter into any agreement for employment for any specified period of time or to make any agreement unless it is in writing and signed by the owner of the company.

e-signature: