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"
*
" indicates required fields
Date of Application
*
MM slash DD slash YYYY
First Name
*
Middle Name
Last Name
*
Email Address
*
Daytime Phone
*
Nighttime Phone
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
*
Are you legally able to work in the United States? (Proof of identity and legal authority to work in the United States is a condition of employment)
*
Yes
No
What position are you applying for?
*
Server
Host
Bartender
Line Cook
Prep Cook
Dishwasher/Utility
Other
At which location would you like to work?
*
Midlothian
Short Pump
Charlottesville
Durham
Carytown
If Other, explain here
Desired starting wage
What employment are you seeking?
First Choice
Second Choice
Third Choice
Have you ever been employed at Burger Bach?
*
Yes
No
If Yes, what location?
What was the date of your employment at that location?
MM slash DD slash YYYY
Who Referred you to Burger Bach restaurant?
Date available for employment
*
MM slash DD slash YYYY
Have you ever been convicted of a felony which has not been annulled or sealed by a court? (convictions will not necessarily exclude you from employment, but date and type of conviction may be considered for job placement.)
*
Yes
No
If YES, please explain
WORK SCHEDULE AVAILABILITY
What shifts are you available to work? We have shifts from 7:00 AM to 12:00 AM - DAY OF THE WEEK
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
TIME OF DAY (Ex: 7am to 6pm)
*
Are you willing to work a split shift?
*
Yes
No
Are you willing to come in early or stay late in case of emergency?
*
Yes
No
Are you willing to work holidays/weekends (Friday-Sunday)?
*
Yes
No
How many hours do you expect to work?
*
EDUCATION - HIGH SCHOOL
High School
Street Address
City
State/Province
ZIP / Postal Code
Courses majored in
Last year completed
Diploma / Degree
Yes
No
EDUCATION - COLLEGE
College
Street Address
City
State/Province
ZIP / Postal Code
Courses majored in
Last year completed
Diploma / Degree
Yes
No
OTHER EDUCATION
Other Education
Street Address
City
State/Province
ZIP / Postal Code
Courses majored in
I affirm that all information in this application is true and complete.
Yes
No
Last year completed
Diploma / Degree?
Yes
No
PERSONAL REFERENCE 1
Ref 1 Name
Ref. 1 Street Address
Ref. 1 Apartment, suite, etc
Ref. 1 City
Ref. 1 State/Province
Ref. 1 ZIP / Postal Code
Ref. 1 Phone
Ref. 1 Relationship
Ref. 1 Years Acquainted
PERSONAL REFERENCE 2
Ref 2 Name
Ref. 2 Street Address
Ref. 2 Apartment, suite, etc
Ref. 2 City
Ref. 2 State/Province
Ref. 2 ZIP / Postal Code
Ref. 2 Phone
Ref. 2 Relationship
Ref. 2 Years Acquainted
PERSONAL REFERENCE 3
Ref 3 Name
Ref. 3 Street Address
Ref. 3 Apartment, suite, etc
Ref. 3 City
Ref. 3 State/Province
Ref. 3 ZIP / Postal Code
Ref. 3 Phone
Ref. 3 Relationship
Ref. 3 Years Acquainted
WORK EXPERIENCE: EMPLOYER 1
Emp. 1 Phone
Emp. 1 Street Address
Emp. 1 Apartment, suite, etc
Emp. 1 City
Emp. 1 State/Province
Emp. 1 ZIP / Postal Code
Emp. 1 Supervisor
Emp. 1 Title
Emp. 1 Your Position
Emp. 1 Start Date
MM slash DD slash YYYY
Emp. 1 Ending Date
MM slash DD slash YYYY
Emp. 1 Starting Wage
Emp. 1 Ending Wage
Emp. 1 Reason for Leaving
WORK EXPERIENCE: EMPLOYER 2
Emp. 2 Phone
Emp. 2 Street Address
Emp. 2 Apartment, suite, etc
Emp. 2 City
Emp. 2 State/Province
Emp. 2 ZIP / Postal Code
Emp. 2 Supervisor
Emp. 2 Title
Emp. 2 Your Position
Emp. 2 Start Date
MM slash DD slash YYYY
Emp. 2 Ending Date
MM slash DD slash YYYY
Emp. 2 Starting Wage
Emp. 2 Ending Wage
Emp. 2 Reason for Leaving
WORK EXPERIENCE: EMPLOYER 3
Emp. 3 Phone
Emp. 3 Street Address
Emp. 3 Apartment, suite, etc
Emp. 3 City
Emp. 3 State/Province
Emp. 3 ZIP / Postal Code
Emp. 3 Supervisor
Emp. 3 Title
Emp. 3 Your Position
Emp. 3 Start Date
MM slash DD slash YYYY
Emp. 3 Ending Date
MM slash DD slash YYYY
Emp. 3 Starting Wage
Emp. 3 Ending Wage
Emp. 3 Reason for Leaving
I AFFIRM THAT ALL INFORMATION IN THIS APPLICATION IS TRUE AND COMPLETE.**
*
Yes
No
Applicant Signature
*
Date
*
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