Basic Info

Items marked with an asterisk are required.

Name (Last, First, Middle)*
Phone Number*
Email Address*
Address
City 
State
Zip Code

Position you are applying for
I am applying for a:
Are you over the age of 18? Yes     No
If "No," please provide your date of birth.
If hired, what date can you start work?
Education
Highest Grade Completed Type of Degree/Certificate Date of Completion
High/Trade School Name & Location
9 10 11 12
College Name & Location
1 2 4
Employment History
Employer’s Name, Address, Phone# Dates Started-Ended Your Position Supervisor Wage Reason for Leaving
Personal Data
Are you authorized to work in the USA?     
Have you ever been convicted of a crime?     
If yes, what crime and where?
Do you have reliable transportation to and from work during hours when public transportation might not be available?     
Do you smoke?     
Do you have any allergies, physical or mental ailments which would interefere with the preformance of your duties?
Availability

Choose "Yes," "No," or "Maybe" for the shifts that you can work, cannot work, or might be able to work/have limited availability to work, respectively. If "No" or "Maybe" is marked, please give a brief explanation in the box below.

Shifts Monday Tuesday Wednesday Thursday Friday Saturday Sunday
11 am – 6 pm
Y N M
Y N M
Y N M
Y N M
Y N M
Y N M
Y N M
5 pm – 12 am
Y N M
Y N M
Y N M
Y N M
Y N M
Y N M
Y N M
If "No" or "Maybe" is marked, please give a brief explanation:
Does your availability change due to school schedule? If so, when?