EMPLOYMENT APPLICATION
Please complete all required fields and submit.
Email address *
PERSONAL INFORMATION
Last Name *
First Name *
Middle Initial
Home Phone
Cell Phone
Email *
Current Address
Address & Street *
City *
State *
Zip *
Permanent Address (if different than above)
Address & Street
City
State
Zip
POSITION INFORMATION
POSITION Applied For *
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? *
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:
EMPLOYMENT HISTORY #1
Please begin with most recent employer.
Company Name *
Type of Business *
Address *
Telephone *
Employed From *
Month/Year
Employed To *
Month/Year
Last Position Held *
Ending Wage/Salary *
Supervisor Name *
May we contact now? *
Reason For Leaving *
EMPLOYMENT HISTORY #2
Company Name
Type of Business
Address
Telephone
Employed From
Month/Year
Employed To
Month/Year
Last Position Held
Ending Wage/Salary
Supervisor Name
May we contact now?
Clear selection
Reason For Leaving
EMPLOYMENT HISTORY #3
Company Name
Type of Business
Address
Telephone
Employed From
Month/Year
Employed To
Month/Year
Last Position Held
Ending Wage/Salary
Supervisor Name
May we contact now?
Clear selection
Reason For Leaving
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.
EDUCATION, TRAINING, EXPERIENCE
High School
Name
Location
# Years
Diploma or Degree Obtained
College/University
Name
Location
# Years
Diploma or Degree Obtained
Post Graduate School
Name
Location
# Years
Diploma or Degree Obtained
Certificate Program
Name
Location
# Years
Diploma or Degree Obtained
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 *
Company & Location *
Telephone *
Reference #2
Name/Title *
Company & Location *
Telephone *
Reference #3
Name/Title *
Company & Location *
Telephone *
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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