Employment – Grab a Java Coffee

Application for Employment:

We consider applicants for all positions on the basis of qualifications and without regard to race, color, national origin, citizenship, religion, sex, pregnancy, age, disability, sexual orientation, gender identity, genetic information/history, military status, use of lawful products during non-work hours and/or any other legally protected characteristic or condition.

This application will be considered active for 6 months from the date it is submitted. Consideration for employment after 6 months requires a new application.

1Personal Info

2Work Record

3Education

4References

Date of Application

How did you hear about this position?

Position(s) applied for:

I can work (choose all that apply)

Full-time
Part-time
Mornings
Nights
Weekends

Personal Information

Name *

First

Last

If your records are listed under another name, provide name:

Date of Birth *

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you legally eligible to work in the United States?

If hired, you will be required to provide proof of identity and eligibility to legally work in the U.S.

Are you at least 18 years old?

If no, you may be required to provide authorization to work.

Have you ever worked here before?

If yes, when? (Give dates)

Job Title

During the last seven years, have you ever been convicted of a crime (misdemeanor or felony)?

If yes, please explain: (A conviction will not necessarily result in the denial of employment but falsifying your application will.)

Please read the position description before answering the following question.

Can you perform the essential functions of the position(s) for which you are applying with or without a reasonable accommodation, where applicable?

Work Record

Please provide the requested employment information, starting with your most current position.

Employer 1

Name of Employer

Supervisor's Name/Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Positions(s) Held

Describe work performed

Dates Employed

Reason for Leaving

Starting Rate of Pay

Ending Rate of Pay

May we contact this employer for a reference?

Employer 2

Name of Employer

Supervisor's Name/Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Positions(s) Held

Describe Work Performed

Dates Employed

Reason For Leaving

Starting Rate of Pay

Ending Rate of Pay

May we contact this employer for a reference?

Employer 3

Name of Employer

Supervisor's Name/Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Positions(s) Held

Describe work performed

Dates Employed

Reason For Leaving

Starting Rate of Pay

Ending Rate of Pay

May we contact this employer for a reference?

Education

Please identify the education or training which you believe qualifies you for the position you are seeking. (Please read the position description before providing this information)

High School or GED

City/State

Diploma or GED Received?

College Name

City/State

Degree?

Major(s)

College Name

City/State

Degree?

Major(s)

Related Training

Where taken

Certification

Topics Studied

Other

List any other knowledge, skills, or traits not previously mentioned that would help you perform the essential functions of this position:

References

If you have not provided at least three employer references in Section II, please provide three references (other than relatives) that you have known for at least three years. Do not repeat your employer references here. You may include others with whom you have worked.

Name

Occupation

Relationship to You

How long have you known this person?

Phone

Name

Occupation

How long have you known this person?

Relationship to You

Phone

Name

Occupation

How long have you known this person?

Relationship to You

Phone

I understand that, by accepting this application, Java Dog LLC/Grab-a-Java is in no way obligated to provide me with employment, and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at-will, which means that Java Dog LLC/Grab-a-Java and/or I can end the employment relationship at any time with or without notice or cause, consistent with applicable law.

I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any falsified statement or important omission of fact on either this application or during the pre-employment process will result in my application being rejected or, if I am hired, in my employment being terminated.

I also understand that any offer of employment is conditioned upon the verification of my information. I authorize Java Dog LLC/Grab-a-Java to verify any and all information provided on this application and/or during the pre-employment process and I will, upon request, sign other necessary consent forms. I hereby release Java Dog LLC/Grab-a-Java and those who provide information about me, from any/all liability of whatever kind and nature which, at any time, could result from obtaining, and/or having an employment decision based on, such information.

Signed (Type Full Name)

Date / Time