REFERENCES: List the names of two persons, not former employers or relatives, who are familiar with your work and/or character.
Name of Reference: Phone Number:
( )
Business: Years Known:
Name of Reference: Phone Number:
( )
Business: Years Known:
PREVIOUS EMPLOYMENT: List your last two previous employers beginning with the most recent one first.
From: Name of Employer: Phone Number:
( )
Supervisor:
To: Employer Street Address: Reason For Leaving: Position:
Employer City, State, Zip: Salary: Duties:
From: Name of Employer: Phone Number:
( )
Supervisor:
To: Employer Street Address: Reason For Leaving: Position:
Employer City, State, Zip: Salary: Duties:
In Case of Emergency Notify: Relationship
Address Phone
City, State, Zip
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, falsified
statements contained herein shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed to give
you any and all information concerning my previous employment and any pertinent information they may have 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 my wages and salary, may be terminated at any time without prior notice or cause.
Signature: ___________________________________________________ Date: _____________________________________
Hired? Yes ________ No ________ Position:
Salary/Rate Start Date:
Sell, Serve or Deliver Alcoholic Beverages (Yes or No):
Convicted of a Crime (Yes or No):
I-9 W-4 SS Card License ETC Card ETC Deposit Badge Deposit
Hired By: ___________________________________________________ Date: _____________________________________
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signature
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