Personal Information
Name (Last, First, Middle)
Street Address
City/State/Zip
Cell Phone Number
Home Phone Number
Email Address

Employment Desired
Position(s) applying for:
Date Available for work:
Location(s) Desired:	Raynham Easton
How did you find out about this job?	Walk-in Employee Relative On-line Posting Other
If you selected "Other", please specify:
Have you ever worked for this organization before?	- Choose an Option - Yes No
If yes, when and which location:
Desired hours (full time, part time, etc.)
If hired, when would you be able to start?
Availability (Sunday's): Please specify AM/PM
Availability (Monday's): Please specify AM/PM
Availability (Tuesday's): Please specify AM/PM
Availability (Wednesday's): Please specify AM/PM
Availability (Thursday's): Please specify AM/PM
Availability (Friday's): Please specify AM/PM
Availability (Saturday's): Please specify AM/PM
List any friends or relatives employed by this company and their relationship to you:
If hired, do you have a reliable means of transportation to and from work?	- Choose an Option - Yes No
If you are under 18 years of age, can you furnish a work permit?	- Choose an Option - Yes No
If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?	- Choose an Option - Yes No
Are you a veteran?	- Choose an Option - Yes No
If yes, give dates of service: Please specify from / to

Education
Secondary Education (Please select highest level achieved)	- Choose an Option - 9th 10th 11th 12th G.E.D.
College Education (Please select highest level achieved)	- Choose an Option - 1 2 3 4 5 6 7 8
High School Name
High School City & State
High School date of graduation or dates attended
High School degree / diploma
College Name
College City & State
College date of graduation or dates attended
College degree / diploma
Any other forms of education (please specify):
List any special skills or training including ServSafe Food Safety or TIPS alcohol service certification

Work History (please begin with most recent)
1st Reference: Company Name
Current Employer?	- Choose an Option - Yes No
May we contact?	- Choose an Option - Yes No
Address
City/State/Zip
Phone Number
Dates of Employment (please specify From / To):
Salary: Beginning
Salary: Ending
Job Title
Supervisor’s Name & Title
Describe duties briefly:
Specific reason for leaving:
2nd Reference: Company Name
Current Employer?	- Choose an Option - Yes No
May we contact?	- Choose an Option - Yes No
Address
City/State/Zip
Phone Number
Dates of Employment (please specify From / To):
Salary: Beginning
Salary: Ending
Job Title
Supervisor’s Name & Title
Describe duties briefly:
Specific reason for leaving:
3rd Reference: Company Name
May we contact?	- Choose an Option - Yes No
Address
City/State/Zip
Phone Number
Dates of Employment (please specify From / To):
Salary: Beginning
Salary: Ending
Job Title
Supervisor’s Name & Title
Describe duties briefly:
Specific reason for leaving:
4th Reference: Company Name
May we contact?	- Choose an Option - Yes No
Address
City/State/Zip
Phone Number
Dates of Employment (please specify From / To):
Salary: Beginning
Salary: Ending
Job Title
Supervisor’s Name & Title
Describe duties briefly:
Specific reason for leaving:
For references purposes: Have you worked for any of these organizations or attended school under a different name?	- Choose an Option - Yes No
If yes, give name and organization(s)
Have you ever been discharged or asked to resign from any position?	- Choose an Option - Yes No
If yes, please describe:
Are you a party of a non-disclosure or non-compete agreement? (If “Yes”, please provide copy)	- Choose an Option - Yes No
Attach Here:

Authorizations & At-Will Employment Agreement
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Additional Information
Resume