Application For Employment Form (Page 2 of 2) in pdf

Employer 3: __________________________________________________

Supervisor:______________________________________

Position Held: ______________________

Dates (From: To:)____________________ Last Rate of Pay:_____________________________

City/Location:___________________________________________________ State:_____________

Phone:_________________________

Reason for Leaving:

Resigned with Notice

Resigned without Notice

Terminated

Eligible for Rehire?

YES

*Highest Level of Education Obtained: ______________________________________________________________________________________

Additional Information from You

*Have you ever been convicted or pleaded “guilty” or “ no contest” to a felony?

YES

Applicants may check “No” and need not disclose information related to convictions that have been expunged or pardoned or for which the records

relating to such convictions have been sealed or destroyed pursuant to court order.

Answering “Yes” is not an automatic disqualification for consideration of employment.

*Will you receive a satisfactory reference from your current and all previous employers? YES

*Have you ever been discharged or asked to resign by an employer?

YES

Please list any work-related skills: __________________________________________________________________________________________

______________________________________________________________________________________________________________________

Applicant Statement

I certify that all information I have provided in this application and any supporting documents (i.e. resumes, etc) are true to the best of my knowledge. I understand

that a requirement of employment is answering this Application accurately and fully and that I am not qualified for hire or continued employment if I have not

answered accurately and fully. I understand that my falsification, omission, or misstatement of information on this application or at any time during the employment

application process may result in refusal to hire or, if hired, termination.

I authorize investigation of all statements and responses contained herein, authorizing my previous employers to provide to BBRG any pertinent information that they

may have, personal or otherwise, and release all parties from liability for any damage that may result from furnishing the same to BBRG.

Employment with BBRG is entered into voluntarily. All employment with BBRG is at will, meaning that both the Team Member and the Company remain free to

terminate the employment relationship at any time, for any reason, with or without cause or notice. Furthermore, no employment policy, handbook or any other

document shall be construed to create any legal obligation or expressed or implied contract. No representative or Team Member of the Company, other than the

CEO, has the authority to enter into a contrary agreement. Any such agreement must be in writing and signed by both the Team Member and CEO.

I agree that any claim or lawsuit relating to my service with BBRG must be filed no more than six (6) months after the date of the employment action that is the

subject of the claim or lawsuit.

I also understand that if hired, I will be required to provide proof of identity and eligibility to work in the United States and that Federal immigration laws require me to

complete a Form I-9 in this regard.

I understand that BBRG may provide me with additional application documentation pertaining to the state for which I seek employment.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

I Accept

I Decline

*Signature of Applicant

Date

Revised 3/2010