Employment ApplicationDate:

Name: First, MI, Last

Address:

City & State:

Zip Code:

SS Number:

Home Phone: Please include area code

Cell Phone: Please include area code

A Citizen or National of the United States

I am: (Please check a box)

An Alien lawfully admitted for Permanent Residence

An Alien authorized to work in the United States

Full time

Part-time

Full or part-time

Summer Only

Have you ever worked for Dairy Queen before?

If yes, please explain below:NoYesHave you ever been convicted for a crime other than a minor traffic violation?

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Yes No

Email: Alien Number

Expiration

Wilson Avenue Dairy Queen 11 Wilson Ave. Dr. SW

Cedar Rapids, IA 52404

Phone: (319) 364-7888 www.dairyqueen9.com

If no, D.O.B.

Date available to begin work?

Who referred you to this job?

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Hours available to work:

Are you 18 or older?

Education:

Highest Grade Completed Post Secondary Grade Point Average

Please list any activities you are involved in that may interfere with your work schedule:

Yes No If yes, date: If yes, location:

If yes, please list your duties:

Complete & return in person to:

Name:

Who would we contact in case of an emergency?

Home Phone: Work/Cell Phone:

By signing below, I authorize the store owner to investigate all statements made by me on this application form. I understand that misstatements or omissions of information in connection with my application for employment can lead to rejection of my application or dismissal from employment, whenever discovered. I also authorize the store owner to request references from my former employers. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the store owner and myself for either employment of for the providing of any benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the store owner unless expressly made in a written contract of employment signed by me and an authorized representative of the store owner. If I am hired, I understand that my employment would be "at will," which means that I would have the right to terminate my employment at any time and that the store owner would retain a similar right. I Hereby attest that all statements made by me above are true to the best of my knowledge.

Applicant Signature: Date:

Manager Signature: Date:

Complete Address:

Name of last employer:

Name of last supervisor:

Dates of employment:

From: To:

Salary:

From: To:

Phone #:

Last job title:

Reason for Leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

May we contact your employer: NoYes

Previous Employment

dairyqueen9.com