Home Telephone Number

Mobile Telephone

Email Address

Social Security Number

Are you currently employed? If yes, where?

What hours are you available to work?

If needed, are you able to work overtime?

Are you 18 years of age or older?

Are you a U.S. citizen or approved to work in the United States?

Can you provide documentation as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

Will you consent to a mandatory background check?

Do you have any condition which would require job accommodations? If yes, please describe accommodations required below:

Required Accommodations (if none, please enter n/a)

Have you ever been convicted of a criminal offense (felony or misdemeanor)? If yes, please state the nature of the crime(s), when and where convicted and disposition of the case.

(if none, please enter n/a)

High School

Location (city, state)

Graduation year

Part-Time Job Application