PERSONAL INFORMATION

First Name:          Middle Init.:          Last Name:         Soc. Sec. #:

Address:         City:         State:         Zip:

Home Phone:          Cell Phone:         Email:

EMPLOYMENT DESIRED

Applying For: Select a Position Management Full-Time Hourly Part-Time Hourly Any Available         Available to Start: (ex. mm/dd/yyy)         Desired Salary:

Currently Employed? Select Yes No         Reason for Leaving:

Have you been convicted of any crimes within the last 10 years? Yes No

If yes, please describe below.

EMPLOYMENT HISTORY

List in Order of Most Recent First.

Employer Name:         Start Date:         End Date:

Position Held:         Salary: Hr Yr         Reason for Leaving:

Employer Name:         Start Date:         End Date:

Position Held:         Salary: Hr Yr         Reason for Leaving:

Employer Name:         Start Date:         End Date:

Position Held:         Salary: Hr Yr         Reason for Leaving:

May we contact your current employer? Yes No

EDUCATION

Highschool

Name:         City, State:         Years:         Graduated: Yes No Select

Awards/Activities:

College/University

Name:         City, State:         Years:         Graduated: Select Yes No

Awards/Activities:

Name:         City, State:         Years:         Graduated: Select Yes No

Awards/Activities:

REFERENCES

Name:         Address:         City:         State:         Zip:

Phone: (ex. 123456789)         Years Known:

Name:         Address:         City:         State:         Zip:

Phone: (ex. 123456789)         Years Known:

SPECIAL SKILLS

Do you have any other experience, training, qualifications, or skills which you feel make you especially suited for work at The Wooden Nickel? If so,

please list below.

OTHER

Have you ever used a POS machine at another job? Select Yes No         If yes, what kind?

What is your current availability?

Are you able to work on weekends? Select Yes No

ADDITIONAL COMMENTS

Please list any additional comments below.

AGREEMENT

By entering your information below, you agree that you have read and understand the following terms and conditions:

I certify under USC 18 Section 1746 that the information in this application is true and complete to the best of my knowledge. I also authorize

investigation of all statements contained herein including contacting any previous employers and or contacts for reference.

I understand that if hired my employment is at will and that either party may terminate the relationship with or without cause.

First Name:           Last Name: