Omelet House Application For Employment Pre-Employment Questionnaire Equal Opportunity Employer         Personal Information NAME: (Last Name First): Social Security Number: Present Address: City: State: Choose A State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Zip Code: Permanent Address: City: State: Choose A State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Zip Code: Phone Number: Email: Referred By: Employment Desired: Position: Date you can start: Salary Desired: Are you Employed? Yes No If so, may we inquire of your present employer? Yes No Ever applied to omelet house before? Yes No If so When: Education History   Name and Location of School Years Attended Did you Graduate? High School Yes No College Yes No Former Employers (List Below last four employers, starting with the last one first) Date: Month/ Yr Name and Address of Employer Salary Position Reason for leaving From: To:     From: To:     From: To:     From: To:   References: Give the names of three persons not related to you, whom you have known at least one year. Name Address Business Years Known         Authorization       “I certify that the facts contained on this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.       I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, Personal or otherwise, and release the company from all liability for damage that may result from utilization of such information.       I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.       This waver does not permit the release or use of disability-related of medical information in an manner prohibited by the Americans with Disabilities Act (ADA) and other relevant a federal and state laws” Today’s Date: Applicant Signature:Selecting “yes” in this online registration form is recognized as a legal endorsement. Actual signature will be obtained before consideration of employment.                                                                                      Yes No