Bertz Sports Bar and Grill Information


	APPLICANT INFORMATION


Last Name*				First Name*
Address*
Address2
City*		State*		Zip*
Phone*				Cell
Email*


Position Applying For


Are You:
Authorized to work in the U.S.?	YesNo
Over the age of 18?	YesNo
Over the age of 21?	YesNo
Have you ever worked for this company?	YesNo
If so, when?


	PREVIOUS EMPLOYMENT


Company		Phone
Address		Supervisor
Position Title		Reason for leaving
From		To


	Skills Used


May we contact your previous supervisor for a reference?	YesNo


Company		Phone
Address		Supervisor
Position Title		Reason for leaving
From		To


	Skills Used


May we contact your previous supervisor for a reference?	YesNo


Company		Phone
Address		Supervisor
Position Title		Reason for leaving
From		To


	Skills Used


May we contact your previous supervisor for a reference?	YesNo


	EDUCATION


Do you possess a high school diploma or GED?	YesNo


	School Name/Address/City/State


Post-Secondary School Name
Address
Did you graduate?	YesNo
Degree Earned


	List all relevant licenses, certifications or registrations you possess. Also identify other educational experience relevant to the position you are applying for.


	ADDITIONAL SKILLS OR QUALIFICATIONS


	MILITARY SERVICE


Branch		From		To


Did you serve on active duty?	YesNo	Type of Discharge


	REFERENCES

	Please list three professional references.


Full Name		Relationship
Address		Phone
Email

Full Name		Relationship
Address		Phone
Email

Full Name		Relationship
Address		Phone
		Email


	DISCLAIMER AND SIGNATURE


	I certify that the information on this application and its supporting documents is accurate and complete. I understand, and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize the employer to investigate and verify all statements contained in this application and supporting materials.


*			I have read the above policies and am in agreement.


Name*		Date*