Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the presence of a non-related medical condition or handicap.

Name_______________________________________________________Date___________________

Address___________________________________________________Phone #___________________

City_____________________State_____Zip__________Social Security #_______________________

DOB_________________Are you a citizen of the United States of America? [ ] Yes [ ] No

Have you applied here before? [ ] Yes [ ] No When?______Position applied for?_________________

Start When_______________ [ ] Full time [ ] Part time [ ] Temporary [ ] Other__________________

EMPLOYMENT EXPERIENCE; Start with your present job or last job. Include military assignments and other volunteer activities. Exclude organizational names which indicate race, color, religion, sex, or national origin

Employer 1__________________________________________________________________________

Address___________________________________City________________State_____Zip__________

Phone #________________Supervisors’ Name_____________________________________________

Job Title______________________Reason for leaving_______________________________________

Dates of Employment: From_________To__________Salary or Hourly rate______________________

Employer 2__________________________________________________________________________

Address___________________________________City________________State_____Zip__________

Phone #________________Supervisors’ Name_____________________________________________

Job Title______________________Reason for leaving_______________________________________

Dates of Employment: From_________To__________Salary or Hourly rate_____________________

Employer 3__________________________________________________________________________

Address___________________________________City________________State_____Zip__________

Phone #________________Supervisors’ Name_____________________________________________

Job Title______________________Reason for leaving_______________________________________

Dates of Employment: From_________To__________Salary or Hourly rate______________________

EDUCATION

Schools/Collages Attended: # Years Year Grad. Degree

____________________________________________________ _______ _______ ___________

____________________________________________________ _______ _______ ___________

____________________________________________________ _______ _______ ___________

Describe any special qualifications for this job:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Can you get an OLCC License? Yes or No (Please Circle one Answer) Or if you already have one:

OLCC Permit #_______________________________State__________Expiration_______________

Drivers License #_______________________________State__________Expiration_______________

Are you a veteran of the U.S. Military service? [ ] Yes [ ] No

I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize investigations of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given on my application or interview may result in termination.

Signature___________________________________________________Date_____________________

Remarks____________________________________________________________________________

___________________________________________________________________________________

__________________________________________Interview report by__________________________