Which location are you applying to? Which location are you applying to?AnkenyCedar RapidsDes Moines

First Name

Last Name

Street Address

Address Line 2

ZIP Code

City, State

Phone

Alternate Phone

Are you 19 years or older? Are you 19 years or older? Yes No

Have you ever been convicted of a felony? (This will not exclude you.) Have you ever been convicted of a felony? (This will not exclude you.) Yes No

Please explain.

Position Desired (Check all that apply.) Position Desired (Check all that apply.) Server Line Cook Busser Assistant Manager Bartender Expediter Prep Cook Dishwasher

When is the best time to reach you? When is the best time to reach you? Morning Afternoon Evening

Please list the hours you are available to work each week. (Ex: Monday 10am - 4pm, Tuesday 4pm - Midnight, etc.)

Have you ever applied to this company before? Have you ever applied to this company before? Yes No

Have you ever worked for this company before? Have you ever worked for this company before? Yes No

Most Recent Employer (Company Name)

Dates Worked (Month/Year - Month/Year)

Starting and Ending Pay (Ex: $8/hr - $10/hr)

Address (Street Address, City, State, Zip)

Supervisor Name

Phone

Job Title

Are you currently employed here? Are you currently employed here? Yes No

Reason for Leaving

Second Most Recent Employer (Company Name)

Dates Worked (Month/Year - Month/Year)

Starting and Ending Pay (Ex: $8/hr - $10/hr)

Address (Street Address, City, State, Zip)

Supervisor Name

Phone

Job Title

Are you currently employed here? Are you currently employed here? Yes No

Reason for Leaving

Third Most Recent Employer (Company Name)

Dates Worked (Month/Year - Month/Year)

Starting and Ending Pay (Ex: $8/hr - $10/hr)

Address (Street Address, City, State, Zip)

Supervisor Name

Phone

Job Title

Are you currently employed here? Are you currently employed here? Yes No

Reason for Leaving

High School Name

Number of Years Attended

Address (Street Address, City, State, ZIP)

Graduated? Graduated? Yes No

College Name

Number of Years Attended

Address (Street Address, City, State, ZIP)

Graduated? Graduated? Yes No

Reference Name

Company

Address (Street Address, City, State, ZIP)

Phone

Years Known

Reference Name

Company

Address (Street Address, City, State, ZIP)

Phone

Years Known

Please read and check each box before signing below and submitting Please read and check each box before signing below and submitting By typing my name below, 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 termination. I authorize investigation of all statements contained herein and the references and employers 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 the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

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Today's Date