EMPLOYMENT APPLICATION
Please complete all required fields and submit.
PERSONAL INFORMATION
Last Name
Your answer
First Name
Your answer
Middle Initial
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Current Address
Address & Street
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Permanent Address (if different than above)
Address & Street
Your answer
City
Your answer
State
Your answer
Zip
Your answer
POSITION INFORMATION
POSITION Applied For
Your answer
TIME BASE, DAYS and HOURS you are willing to work? (Please check all that apply.)
Required
# HOURS per week (average) would you like to work?
Your answer
Are you available to work overtime if necessary?
If hired, what date can you start work?
MM
/
DD
/
YYYY
Please indicate any other scheduling restrictions below:
Your answer
EMPLOYMENT HISTORY #1
Please begin with most recent employer.
Company Name
Your answer
Type of Business
Your answer
Address
Your answer
Telephone
Your answer
Employed From
Month/Year
Your answer
Employed To
Month/Year
Your answer
Last Position Held
Your answer
Ending Wage/Salary
Your answer
Supervisor Name
Your answer
May we contact now?
Reason For Leaving
Your answer
EMPLOYMENT HISTORY #2
Company Name
Your answer
Type of Business
Your answer
Address
Your answer
Telephone
Your answer
Employed From
Month/Year
Your answer
Employed To
Month/Year
Your answer
Last Position Held
Your answer
Ending Wage/Salary
Your answer
Supervisor Name
Your answer
May we contact now?
Reason For Leaving
Your answer
EMPLOYMENT HISTORY #3
Company Name
Your answer
Type of Business
Your answer
Address
Your answer
Telephone
Your answer
Employed From
Month/Year
Your answer
Employed To
Month/Year
Your answer
Last Position Held
Your answer
Ending Wage/Salary
Your answer
Supervisor Name
Your answer
May we contact now?
Reason For Leaving
Your answer
ADDITIONAL INFORMATION
If hired, do you have a reliable means of transportation to and from work?
Are you at least 18 years old? (Or if not do you have a work permit?)
Are you 21 years or older (if applying for bartender position)?
If hired, can you provide proof of your legal right to work in the United States?
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? If not, please describe the functions that cannot be performed.
Have you ever been convicted of a criminal offense (felony or serious misdemeanor involving violent or fraudulent conduct?) You need not disclose minor traffic violations or marijuana related convictions offenses that are more than two years old. If yes, state the nature of the crime(s), where and when convicted and disposition of the case.
OTHER RELEVANT EXPERIENCE, SKILLS or SPECIAL TRAINING
E.g. computer knowledge, language skills, etc.
Your answer
EDUCATION, TRAINING, EXPERIENCE
High School
Name
Your answer
Location
Your answer
# Years
Your answer
Diploma or Degree Obtained
Your answer
College/University
Name
Your answer
Location
Your answer
# Years
Your answer
Diploma or Degree Obtained
Your answer
Post Graduate School
Name
Your answer
Location
Your answer
# Years
Your answer
Diploma or Degree Obtained
Your answer
Certificate Program
Name
Your answer
Location
Your answer
# Years
Your answer
Diploma or Degree Obtained
Your answer
PROFESSIONAL REFERENCES
Please list three professional references (not related to you) that have knowledge of your performance over the past three years.
Reference #1
Name/Title
Your answer
Company & Location
Your answer
Telephone
Your answer
Reference #2
Name/Title
Your answer
Company & Location
Your answer
Telephone
Your answer
Reference #3
Name/Title
Your answer
Company & Location
Your answer
Telephone
Your answer
Please Read Carefully Before Submitting
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Luella’s to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Luella’s, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview, which may be granted or during my employment, if hired, is intended to create an employment contract between me and Luella’s. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without notice, at the option of either myself or Luella’s, and that no promises or representations contrary to the foregoing are binding on Luella’s unless made in writing and signed by me and the Luella’s designated representative.

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