Which position are you applying for?
Today's Date *
Today's Date
Name *
Name
Address *
Address
Phone *
Phone
Type of employment requested
Days available for work *
Please list all the days of the week that you are available for work over the next 6 months.
Hours available for work *
Please list all the shifts that you are available for work over the next 6 months.
Education
Please choose the education level you have achieved or are working towards achieving.
Location of last school attended
Location of last school attended
Criminal Background
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
Transportation
If you are answering Yes, please complete the following four fields. If you are answering no you can move on the References section.
Driver's license expiration date
Driver's license expiration date
References
Please list a reference, other than relatives or previous employers. *
Please list a reference, other than relatives or previous employers.
Phone *
Phone
Please list a reference, other than relatives or previous employers. *
Please list a reference, other than relatives or previous employers.
Phone *
Phone
Employment
Please list your work experience beginning with your most recent job held. If you were self-employed, give firm name.
Address
Address
Phone
Phone
Supervisor
Supervisor
From
From
To
To
Reason for leaving
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
Disclosure and release
If not, who did?
If not, who did?
Disclosure and release *
By submitting this application, I understand that: All information I provide is subject to a thorough review and confirmation by a LostCoffee and Human Resources; and I may be disqualified for employment if LostCoffee determines that I have provided any deliberately false, misleading, inaccurate, incomplete or knowingly untruthful answers to any question(s). If selected for an in-office interview, I will be asked to affirm this electronic signature with an actual signature. I hereby certify that all of the foregoing information I have provided is accurate and true to the best of my knowledge.