Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position applying for

Have you ever applied to Wine & Roses

Yes

If Yes, please provide dates

If you checked No, please input 'N/A' below

Date you can start

Applying for

Full Time

Part Time

Total Hours available

Please check the days you are available to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please check the hours you are available to work

Open availability

Restricted availability

If you checked restricted availability, please provide restrictions

Indicate the days and the hours that you are NOT available to work. (Input 'N/A' below)

If hired, and under 18, can you furnish proof of age and/or a work permit?

Yes

Over 18 years of age

If hired, can you provide proof of identity and authorization to work in the U.S.?

Yes

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?

Yes

How did you learn about this company and position?

(If someone referred you, please indicate their name and department)

Highest Grade Completed

Middle School

Some High School

High School Diploma

Some College

College Associates Degree

College Bachelors Degree

Masters Degree or Other

High School Name / City,State

College or University Name / City, State / Major, Minor / Degree

Provide last college or university attended, and whether or not degree was obtained. (Input 'N/A' if not applicable.)

When responding to the following questions, you may omit information which would disclose race, gender, religion, creed, national origin, or disability

Academic honors or special recognition

Extra curricular activities

Offices Held

Other night school, correspondence, home study or courses

EMPLOYMENT EXPERIENCE AND REFERENCES

Starting with your latest employer, please provide the following information about the last three companies for which you have worked. You must complete this section even if attaching a resume.

1. Company

Address Information

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Started

Date Left

Position Held

Job Responsibilities

Reason for leaving

Supervisor Name & Title

Supervisor Telephone

2. Company

If you do not have additional work experience, input 'N/A' into the below fields

Address Information

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Started

Date Left

Position Held

Job Responsibilities

Reason for leaving

Supervisor Name & Title

Supervisor Telephone

3. Company

If you do not have additional work experience, input 'N/A' into the below fields

Address Information

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Started

Date Left

Position Held

Job Responsibilities

Reason for leaving

Supervisor Name & Title

Supervisor Telephone

Additional References

Give name, address & telephone of 3 professional references (no relatives):

Physical Examinations

All new hires for the following positions will be required to undergo a company-paid physical examination: Yard/Maintenance, Housekeeping & Dishwasher positions. All information from this examination will be kept confidential and disclosed only to supervisors, managers, and safety or rescue personnel who have a need to know. I agree and herby consent to a physical examination paid by Wine & Roses, LLC for any of the above listed jobs. I understand that I am required to take a pre-employment physical examination after receiving an offer of employment and before beginning the work assignment. However, every offer of employment is contingent upon an employee's successful completion of the physical examination.

Add initials in text below in acknowledgement that you have read and understood the Physical Examinations.

I certify that the statements and information furnished by me in this application are true and correct and I understand that falsification of such statements and information is grounds for dismissal at any time the company becomes aware of the falsified information. In consideration of my employment, I agree to conform to the rules and regulations of your company and acknowledge that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the company or myself. I further understand that no policy, benefit, or procedure contained in any employee handbook creates an employment contract for any period of time, and not terms or conditions of employment contrary to the foregoing should be relied upon, except for those made in writing by a designated officer of the Company. All the forgoing information is truthful and factual and it is my understanding that should falsification be discovered it will constitute grounds for non-acceptance or dismissal. I agree and hereby authorize Wine & Roses, LLC to conduct a background inquiry to verify the information on this application and any company form completed by me. I authorize all previous employers or other persons who have knowledge of me or my records to release such information to Wine & Roses, LLC. I hereby release those companies and persons of Wine & Roses, LLC from all claims or liabilities whatever that may arise by such disclosures or such investigation.

Add initials in text box below in consent.

Signature of Applicant

Date

YYYY

We are an equal opportunity employer and do not discriminate against any applicant because of race, color, religion, sex/gender, gender identity, gender expression, sexual orientation, marital status, medical condition, military or veteran status, age, national origin, disability, or genetic information.

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