Jefferson’s EMPLOYMENT APPLICATION Application For Employment Step 1 of 7 14% Location*Please SelectAdairsville, GAAlbertville, ALFort Payne, ALGadsden, ALHoover, ALJacksonville, ALOwens Cross Roads, ALOxford, ALOpelika, ALRainbow City, ALScottsboro, ALCalhoun, GACartersville, GACarrollton, GACedartown, GADalton, GAHiram, GARinggold, GARome, GARockmart, GASummerville, GATrenton, GAVilla Rica, GALawrence, KSLenexa, KSTopeka, KSJoplin, MONorth Kansas City, MOBrentwood, TNColumbia, TNFairview, TNKimball, TNManchester, TNMurfreesboro, TNWinchester, TN Applicant InformationName First Middle Last Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Position Applying For: Back of House Team Member Front of House Team Member Management Will you have reliable transportation if hired?DescribeAre you at least 18 years old? Yes No If you are under 18 years of age, can you furnish a work permit? Yes No Have you been convicted of a crime? Yes No If yes, state the nature of the offense and disposition of the case.(Massachusetts applicants should not include misdemeanor convictions; California applicants should not include marijuana-related convictions that occurred more than 2 years prior to the application date.)Are you a veteran? Yes No If yes, give dates of service:List any special skills or training: Employment InformationType of employment you are looking for: Full Time Part Time Temporary What hours and shift(s) would you prefer to work?List times you are not available to work:Are you willing to work overtime? Yes No Which of the following are you willing to work? Weekends Holidays Are you currently employed? Yes No If hired, when would you be able to start?Have you ever worked for this organization before? Yes No If yes, named used:Have you ever been discharged or asked to resign from any position? Yes No If yes, please describe: Education (Select highest level achieved) Elementary School Middle School High School College Name of school & Major (if applicable) Work HistoryCompanyLocation (City, State)Dates of EmploymentJob TitleDescribe duties briefly:Specific reason for leaving:CompanyLocation (City, State)Dates of EmploymentJob TitleDescribe duties briefly:Specific reason for leaving:CompanyLocation (City, States)Dates of EmploymentJob TittleDescribe duties briefly:Specific reason for leaving: Authorization & At-Will Employment Agreement (please read carefully, then enter your name and the date below) I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification form my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired. I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations. I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician. AT-WILL EMPLOYMENT AGREEMENT I understand and agree that nothing contained in this application, or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the companyBs President is authorized to change the employment-atwill status and such a change can only be done in writing. I have read, understand, and agree to the above.Name First Last Date CAPTCHA
