Application For Employment

Please Print All Information HOME PAGE
		Date:
Last Name:	First Name:	Middle Name:
Address:	Number	Street:
City:	State:	Zip Code:

Telephone Numbers:

Position Applied For:
Shifts willing to work: (check all that apply)
	(	Day	(	Mid-Day			(		Evening
Salary or Hourly Rate expected:					week	hour		(circle one)

Have you ever been employed by us before?

(

Yes

(

If Yes, Date:

Are you currently employed?

(

Yes

(

May we contact your present employer?

(

Yes

(

Are you 21 Years or older?

(

Yes

(

Are you prevented from lawfully becoming employed in this country due to Visa or Immigration status?
(Proof of citizenship or immigration status is required upon employment.)

(

Yes

(

You are available to work:

(

Full Time

(

Part Time

(

Temporary

Date you can begin work:

Have you been convicted of a crime within the last seven (7) years?

(Other than a traffic violation.) (Conviction will not necessarily disqualify an applicant from employment)

(

Yes

(

If yes, please explain:

Education

School Address	Credits Earned	Major	Diploma/Degree
High School:
College:
Technical/Other:

List below all present and past employment, beginning with your most recent. All times must be accounted for whether employed or not. Attach an additional sheet if necessary.

Name and Address of Company and Type of Business	From		To		Describe in detail work you did and your title	Weekly Start Salary or Hourly Rate	Weekly End Salary or Hourly Rate	Reason for Leaving	Name, Title and Phone Number of Your Supervisor
	MO	YR	MO	YR

Describe in detail any specialized training, computer or office equipment skills, certification, licenses or on-the-job training programs you have completed:

Licenses And Certifications:

List any licenses or certifications held and the dates obtained: (Bartender License, Food Safety Certification, etc.)

1.____________________________________________	2.____________________________________________
3.____________________________________________	4. 4. ____________________________________________
4.	4.

Skills and Abilities:

____________________________________________________________________________________________________

Personal References:

Name:	Company:	Phone:
Address:		Relationship:
City/ State/ Zip:
Name:	Company:	Phone:
Address:		Relationship:
City/ State/ Zip:
Name:	Company:	Phone:
Address:		Relationship:
City/ State/ Zip:

APPLICANT’S STATEMENT and CONDITIONS OF EMPLOYMENT

(Please read carefully before signing.)

I certify that the answers given by me in this employment application are true, correct and complete. I agree that the company shall not be liable, in any respect, if my employment is terminated because of misstatements or pertinent omissions made by me in this application. Moreover, I understand that all offers of employment are contingent upon passing the company's prescribed physical examination, drug screen and background screening program in place.

I agree, as a condition of my employment, to submit to a medical examination, blood test, or urinalysis test if requested and paid for by the company. I further agree to the search or examination of myself or personal property while on the company's premises or while conducting its business elsewhere, I also authorize any company, school, police or security personnel, or other person to give any information regarding my employment, habits, ability, or any other characteristics whatsoever, together with any information they have regarding me whether or not it is in their records. I hereby release all physicians, examiners, companies, schools, or other persons from liability for any damages whatsoever for such testing, examining, or issuing this information. It is agreed and understood that completion of this application does not mean a job opening exists and in no way obligates the company to employ me.

In the event of employment, I will comply with all company rules and regulations as established from time to time including the company's substance abuse policy. I am willing to work all assigned overtime or other special work assignments as requested by the company. Furthermore, since the company does not offer contracts of employment (unless signed by the President), I understand that nothing contained herein is intended to create a contract between the company and me for either employment or the provision of any compensation or benefits. I understand that I have the right to terminate my employment at any time and likewise, the company has the same right.

I hereby understand and acknowledge that any employment relationship with this Company is of an “At-Will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time, with or without notice, with or without cause. It is further understood that this “At-Will” employment relationship may not be changed by any written document or by verbal agreement unless such change is specifically acknowledged in writing by an authorized Executive of this Company. I also understand that Dominic’s Inc., dba Belknap Liquor & Lounge, retains the right to amend, modify, add or delete any or all policies or procedures at its sole and absolute discretion.

During my employment with Dominic’s Inc., dba Belknap Liquor & Lounge, and after my employment ends, I agree not to disclose any confidential or proprietary information regarding operating and trade secrets. I further agree that with respect to any civil litigation involving Dominic’s Inc., in which I am a potential witness and which does not involve an actual or potential claim by me personally, I will not discuss the facts of the case with any third parties without first notifying Dominic’s Inc., or unless a representative or attorney of Dominic’s Inc. is present. A copy of this form may be used as the original. The use of results from this form and/or tests will be used for prudent employment decisions.

This application is valid for sixty days from the application date unless renewed in person or in writing.

Applicant’s Signature:

Date: