Personal Data

Your Name (Last, First, Middle)

Social Security Number

Street Address

City, State, Zip

Date Available To Begin Work

Type of Employment
 Full Time Part Time

Are You Under The Age of 18?
 Yes No

Do you have a reliable method of transportation?
 Yes No

Can You Work Overtime?
 Yes No

Position Applied For

Salary Desired

Emergency Contact

Name

Telephone

Relationship

State the days and hours that you can work in the section below. If there are any on which you cannot work, indicate the day and explain why.

Enter the days and hours for every day of the week

Stocking shelves, moving beer kegs, general cleaning and lifting/carrying items (sometimes weighing up to 50 lbs) are required in the course of employment. Can you perform these duties?
 Yes No

Education Background

College: Name & Location

Course of Study

Degree/Diploma

Years Attended

High School: Name & Location

Course of Study

Degree/Diploma

Years Attended

Other: Name & Location

Course of Study

Degree/Diploma

Years Attended

U.S. Military Service

Branch of Service

Dates of Miltary Service (from-to)

Discharge
 Honorable Dishonorable

If Dishonorable Explain:

Employment History

Most Recent Employer

Dates of Employment

Supervisor

Pay Rate

Address & Phone Number

Reason for Leaving

Next Recent Employer

Dates of Employment

Supervisor

Pay Rate

Address & Phone Number

Reason for Leaving

Next Recent Employer

Dates of Employment

Supervisor

Pay Rate

Address & Phone Number

Reason for Leaving

May we contact the employers listed above?
 Yes No

"I attest that all information provided is true, accurate, and current"
 I Agree I Do Not Agree

Date