Platte River Restaurant Online Application Form

APPLICANT INSTRUCTIONS

If you need help filling out this application form or for any phase of the employment process, please contact us and every effort will be made to accommodate your needs in a reasonable amount of time. Please read “APPLICANT NOTE below”.

Today's Date: / / (MM/DD/YYYY)

PERSONAL INFORMATION

E-Mail:

First Name: Middle Initial: Last Name:

Home Telephone: (000-000-0000)
Mobile Telephone: (000-000-0000)

Current Address:

Street Address:
City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Prior Address:

Street Address:
City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Are you 18 years or older? Yes No
Do you have reliable means of transportation ? Yes No
Have you ever worked for this Company or any of it's subsidiaries before? Yes No
If Yes - give date: (MM/DD/YYYY)

APPLICANT NOTE:

This application form is intended for use in evaluation our qualifications for employment. This in not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, martial status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Affirmative action hiring may be requested by qualified applicants. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After and offer of employment, and prior to reporting to work, you are required to submit a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

AVAILABILITY:

For which position are you applying:
What date can you start? (MM/DD/YYYY)
What category would you prefer? Full Time Part Time
For what shifts are you available?

EDUCATION:

Please choose highest grade level completed: Select Grade 7 8 9 10 11 12 13 14 15 16 16+
If your schools are under a different name than above, please enter that name:

	Name of Institution	City/State	Graduate?	Degree
High School			Yes/No Yes No
College			Yes/No Yes No
Other			Yes/No Yes No

SECURITY:

List states and counties of residence for the past seven years:

Have you used any names or Social Security Numbers other than those on this page? If so, Please list:

Have you been convicted of, or served time for a felony in the past seven years? If so, please describe below. (In accordance with company policy this information will be reviewed for job relatedness and time since last conviction.)

INCIDENT	CITY/STATE	CHARGE

JOB-RELATED:

Please list any skills that pertain to the position for which you are applying.

PREVIOUS EMPLOYERS:

PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if you need FOR EMPLOYERS OUTSIDE THE U.S. A CURRENT FAX NUMBER IS MANDATORY.

MOST RECENT EMPLOYER

Are you currently working for this employer? Yes No If yes may we contact them? Yes No
Phone: (000-000-0000) Fax : (000-000-0000)
Employer # 1 City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Period Employed From: (MM/DD/YYYY) To: (MM/DD/YYYY)
Job Title: Supervisor:
Salary per Hr/Wk/Mo Hour Week Month
Duties :

Reason for Leaving:

SECOND MOST RECENT EMPLOYER

Employer # 1 City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Period Employed From: (MM/DD/YYYY) To: (MM/DD/YYYY)
Job Title: Supervisor:
Salary per Hr/Wk/Mo Hour Week Month
Duties :

Reason for Leaving:

THIRD MOST RECENT EMPLOYER

Employer # 1 City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Period Employed From: (MM/DD/YYYY) To: (MM/DD/YYYY)
Job Title: Supervisor:
Salary per Hr/Wk/Mo Hour Week Month
Duties :

Reason for Leaving:

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EQUAL OPPORTUNITY EMPLOYER (EEO): Applications are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital status, veteran status, medical conditions, handicap, or any other legally protected status.

VOLUNTARY SURVEY:

As Employers/Governmental Contractors, we comply with government regulations, including affirmative action responsibilities where they apply. Solely to help us comply with government record keeping, reporting, and other legal requirements, we request that you please fill out the applicant data record below. We appreciate your cooperation.

This data below is for periodic government reporting and will be kept separate from the application for employment, your cooperation is voluntary.

Choose one of each of the following options:

Gender: Male Female

Race/Ethnic Background: Choose One White Black Hispanic American Indian Alaskan Native Asian/Pacific Islander

Check next to any applicable boxes:

Vietnam Era Veteran

Handicapped Individual

Special Notice to Disabled Veterans, Vietnam Veterans, and Individuals with Physical or Mental Handicaps

Government Contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires them to take affirmative action to employ and advance in employment, qualified disabled veterans of the vietnam era.

Section 503 of the Rehabilitation Act of 1973, as amended, requires government contractors to take affirmative action to employ and advance in employment, qualified handicapped individuals.

If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information, which will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.

If you wish to be identified please choose the option below, then type your name in the box below.

Handicapped Individual Vietnam Era Veteran

Type Your Name Here: (Note: This box is ONLY for those declaring themselves as Handicapped or as a Vietnam Veteran).

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REFERENCES:

Include only individuals familiar with your work ability. Do not include relatives.
Name	Address	Phone	Years Known	Relationship

Select Years 1 2 3 4-5 6-10 11-20 21-30 30+
Select Years 1 2 3 4-5 6-10 11-20 21-30 30+

COMMENTS:

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CERTIFICATION AND RELEASE:
I certify that I have read and understand the applicant note and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in the application may result in rejections of my application or discharge at any time during my employment. (I authorize the company and/or its agents, including consumer reporting bureaus, to verify and of this information. I authorized all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment)

Signature: (Note: By typing in your name and pressing submit, you are electronically signing this document)

Date: / / (MM/DD/YYYY)