Applicant

*Last Name *First Name Middle Initial   Today's Date *Phone Number *E-Mail Address

Address

AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA QU RI SA SC SD TN TX UT VA VT WA WI WV WY     *Address *City *State *Zip Code *Years lived here If residing at current address for less than 2 years, please provide previous address: AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA QU RI SA SC SD TN TX UT VA VT WA WI WV WY Previous Address Previous City Previous State Previous Zip Years lived here

Elegibility

YesNo *Are you legally authorized to work in the U.S.?   YesNo *Are you 18 or older?

Work

BartenderFood ServerDish Machine Operator / Utility Waiter / WaitressHost / HostessBusser / Server Assistant Line Cook & Food Prep* Check all position(s) you are interested in   *What days and times are you available to work?   *Date when you will be available for work   *Expected hourly rate   *How many hours per week you expect to work   YesNo *Are you willing to work holidays?   YesNo *Are you willing to work a split shift?   YesNo *Are you willing to stay late in an emergency?

Transportation

*How long will it take you to get from home to work? *What type of transportation will you use?

Employment Experience (Most current first)

Name of Company Date employment started Date employment ended Name of supervisor Phone number Job title Reason for leaving Name of Company Date employment started Date employment ended Name of supervisor Phone number Job title Reason for leaving Name of Company Date employment started Date employment ended Name of supervisor Phone number Job title Reason for leaving

Education:

YesNo   *Grammar School *Years attended *Did you graduate?   YesNo   Grammar School Years attended Did you graduate?       YesNo   *High School *Years attended *Did you graduate?   YesNo   High School Years attended Did you graduate?   YesNo College Years attended Did you graduate? Subjects studied YesNo College Years attended Did you graduate? Subjects studied YesNo Trade or Business School Years attended Did you graduate? Subjects studied YesNo Trade or Business School Years attended Did you graduate? Subjects studied

Special Training

YesNo *Any special skills, proficiencies, or certifications? If yes, please describe

*How did you hear about Mudsocks Grill?

References: (Please list three persons not related to you, whom you have known at least one year and in a supervisory position)

*Name *Company *Position *Phone # *Years Known   *Name *Company *Position *Phone # *Years known   *Name *Company *Position *Phone # *Years known

Past History

YesNo *Have you ever been convicted of any criminal offense other than minior traffic violations If yes, please explain in detail (A conviction record does not necessarily disqualify you from employment; factors such as the date of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account)

Drug Free Policy

YesNo *Mudsocks Grill is a drug free work place. Do you understand that we are committed to provide for its employees and guests a drug free work place at all time?

Electronic Signature

All applications received by this company will remain active for 30 days. If you still wish to be considered for employment after 30 days, you must fill out a new application. I understand and agree that Mudsocks Grill Hazel Dell, LLC supports the Drug Free Workplace concept and as such may require me to submit to drug/alcohol screenings as a condition of employment or continued employment. These drug/alcohol screenings may be conducted at anytime. I hereby consent to any such screenings and understand and agree that refusal to submit to any drug/alcohol screenings will disqualify an applicant or result in termination of employment. Subject to state law. I understand that Mudsocks Grill Hazel Dell, LLC., has mediation and arbitration programs to resolve employment related disputes. I agree that the exclusive procedure to resolve any such disputes shall be through the Company’s mediation and arbitration programs, and that arbitration proceedings shall be governed by the federal Arbitration Act, conducted by a neutral arbitrator under the American Arbitration Association’s “National Rules for the Resolution of Employment Disputes”. I understand that I am relinquishing the right to file a civil suit based on any and all claims, disputes or controversies, arising out of or related to my application, employment or cessation of employment by the Company. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall result in termination of employment no matter when discovered. I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard. I authorize investigation of all statements contained herein and the references 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 all parties from liability for any damage that may result from furnishing the same to you. I understand and agree that, if hired, my employment is “at will” and for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice and with or without cause.

YesNo   *Have you read and agree to all the statements above? *Type your name in the box above to sign this application