Date    Social Security Number  Telephone

Name
                 Last                           First                       Middle

Address      
                   Street                         City               State         Zip

How long at this address?   How far away do you live from Blue Plate?

If you plan on serving alcohol, are you 18 or older?   Yes No

Marital Status   Single   Married   Divorced

Position Applied For   Pay Scale Expected

Will You Work  Full Time Part Time   If Part Time Why?

Total Days Available Total Hours Available Weekly? When Can You Start?

Hours Available    Monday   Tuesday   Wednesday   Thursday   Friday   Saturday   Sunday
                                    

If you need a certain day of the week off, why?

Please Check The Appropriate Response

Do you currently have a friend/family member employed at Blue Plate   Yes No

Have you ever been employed by Blue Plate before?  Yes No If yes, when?

Are you currently attending school?   Yes No If yes, where?

What are your special interests or hobbies?

What state or country are you originally from?

What is the hardest physical work you've ever performed?

What is your means of transportation?

Employment History: List your three most recent employers, starting with the most recent. Resumes are welcomed but cannot be used as a substitute for the information below.

Employer Telephone Pay Rate

Summarize the nature of the work performed and the job responsibilities.

Address      
                   Street                         City               State         Zip

Job Title  Dates Employed  From To

Supervisor    May we contact for references? Yes No

Reason for Leaving

Employer Telephone Pay Rate

Summarize the nature of the work performed and the job responsibilities.

Address      
                   Street                         City               State         Zip

Job Title  Dates Employed  From To

Supervisor    May we contact for references? Yes No

Reason for Leaving

Employer Telephone Pay Rate

Summarize the nature of the work performed and the job responsibilities.

Address      
                   Street                         City               State         Zip

Job Title  Dates Employed  From To

Supervisor    May we contact for references? Yes No

Reason for Leaving

Why do you want to work at Blue Plate Roadside Cafe?

Please read the certification below and fill-in your name here.

I hereby certify that the information contained in the application is true and correct to the best of my knowledge and agree to have any of the information verified by The Blue Plate Roadside Café unless I have indicated in writing to the contrary. I authorize the references listed above as well as other individuals whom The Blue Plate Roadside Café contacts, to provide The Blue Plate Roadside Café any and all information concerning my previous employment and any other pertinent information that they may have. I understand any misrepresentation, falsification, or material omission of information or this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.

The Blue Plate Roadside Café is an equal opportunity, community based employer, The Blue Plate Roadside Café does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state or federal law.