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Menu
Catering
About
The Cafe
Work Here
Fundraisers
Private Parties
Giftcards
Contact
Name
*
First Name
Last Name
Email
*
Date
MM
DD
YYYY
Social Security Number
*
Present Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Permanent Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
SPECIAL QUESTIONS
DO NOT ANSWER ANY OF THE QUESTIONS IN THIS FRAMED AREA UNLESS THE EMPLOYER HAS CHECKED A BOX PRECEDING A QUESTION, THEREBY INDICATING THAT THE INFORMATION IS REQUIRED FOR A BONA FIDE OCCUPATIONAL QUALIFICATION, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGALLY PERMISSIBLE REASONS.
Are you 18 Years or Older?
*
Yes
No
Foreign Language
What foreign language do you speak/read/write fluently?
Citizen of US
Yes
No
Date of Birth
MM
DD
YYYY
*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Employment Desired
Position
*
Date You Can Start
MM
DD
YYYY
Salary Desired
$
Are you employed now?
Yes
No
If currently employed, ay we inquire of your present employer?
Ever applied for Cockeyed Rooster Cafe before?
If so, when?
Education
Grammar School
Name and location of school
Number of years attended
Did you graduate?
Option 1
Option 2
Subjects studied
High School
Name and location of school
Number of years attended
Did you graduate?
Option 1
Option 2
Subjects studied
College
Name and location of school
Number of years attended
Did you graduate?
Option 1
Option 2
Subjects studied
Trade. Business or Correspondence School
Name and location of school
Number of years attended
Did you graduate?
Option 1
Option 2
Subjects studied
General
Subjects of special study or research work
U.S. Military or Naval Service
Rank
Present Membership in National Guard or Reserves
Former Employers
List below last 4 employers, starting with last one first
Date (Month and Year)
From: / To:
Name of Employer
Address of Employer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Salary
Position
Reason for Leaving
Date (Month and Year)
From: / To:
Name of Employer
Address of Employer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Salary
Position
Reason for Leaving
Date (Month and Year)
From: / To:
Name of Employer
Address of Employer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Salary
Position
Reason for Leaving
Date (Month and Year)
From: / To:
Name of Employer
Address of Employer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Salary
Position
Reason for Leaving
References
Give the names of 3 persons not related to you, whom you have known at least one year.
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business
Years Acquainted
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business
Years Acquainted
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business
Years Acquainted
Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered?
Yes
No
If so, please describe
Have you had a serious illness in the last 5 years?
Yes
No
If so, please elaborate
In case of emergency, notify
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE.”
Date
MM
DD
YYYY
Check here to authorize my signature once application has been submitted.
Authorize Signature
Do NOT Authorize Signature
Thank you!
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