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Are you legally eligible to work in the United States? *
Are you at least 18 years old? *
Have you applied to Peach Valley Cafe before? *
If “yes”, when and for what position?
Date available to start work
Days and times you are available to work? *
Have you ever pled “guilty” or “no contest”, or been convicted of a crime? *
If yes, please provide the date(s) and details
Professional activities or organizations you are involved in
Job-related skills or qualifications
School / # of Years / GPA / Degree Received / Major
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Please list three business/work, school or personal references who are not related to you and are not previous supervisors.
Name / Address / Telephone # / Relationship / Years Known
| * |
Employer 1 Name (Most Recent) *
Employer 1 Dates Employed Range *
Employer 1 May we contact reference?
Employer 1 Business Address
Employer 1 Supervisor's Title
Employer 1 Starting Job Title
Employer 1 Starting Wages/Salary
Employer 1 Final Job Title
Employer 1 Final Wages/Salary
Employer 1 Reason for Leaving
Employer 1 Job Responsibilities *
Employer 2 Dates Employed Range *
Employer 2 May we contact reference?
Employer 2 Business Address
Employer 2 Supervisor's Title
Employer 2 Starting Job Title
Employer 2 Starting Wages/Salary
Employer 2 Final Job Title
Employer 2 Final Wages/Salary
Employer 2 Reason for Leaving
Employer 2 Job Responsibilities *
Employer 3 Dates Employed Range
Employer 3 May we contact reference?
Employer 3 Business Address
Employer 3 Supervisor's Title
Employer 3 Starting Job Title
Employer 3 Starting Wages/Salary
Employer 3 Final Job Title
Employer 3 Final Wages/Salary
Employer 3 Reason for Leaving
Employer 3 Job Responsibilities
I certify that all of the information I have provided is true, complete and correct. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document will disqualify me from further consideration of employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document will be cause for my dismissal at any time without prior notice.
I authorize Peach Valley Cafe to contact my prior employers, and other sources of information regarding my background, credit history, criminal history and/or driving history and I hereby authorize and direct each such employer and source of information to answer any and all questions regarding my prior employment and background. I hereby indemnify Peach Valley Cafe, each of my prior employers and each of the other sources of information contacted and agree to hold them harmless from any and all claims arising from this authorization and direction.
I agree to this statement *