Joseph’s Catering Service Joseph’s Country Manor & Grove 275 Columbia Avenue Depew, New York 14043 Phone: (716) 681-4538 Fax: (716) 681-2667 E-mail josephs@josephscatering.com

P E R S O N N E L R E C O R D

DATE:

Name:

Social Security No.

Address:

Date Of Birth:

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Home Phone:

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U.S. Citizen:

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Gender:

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Female

Dependents:

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Single

Married

Separated

Divorced

Widowed

In Case Of Emergency Notify:

1). Name:

Relationship:

Address:

Phone:

2). Name:

Relationship:

Address:

Phone:

Have You Ever Applied For Employment With Us?

Yes

No

If Yes, What Month & Year?

Relatives Working For Us:

Position (S) Desired:

Pay Expected:

Availability:

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Will You Work Overtime If Asked?

Are You Legally Eligible For Employment In The United States?

Yes

No

When Will You Be Available To Begin Work?

Other Special Training Or Skills (Language, Machine Operation, Etc.)

How Did You Learn Of Our Organization?

EDUCAT I ON

School

Name and Location of School

Course Of Study

No. Of Years Completed

Did You Graduate?

Degree Or Diploma

College

High

Elementary

Have You Ever Been Convicted Of A Crime In The Past Ten Years, Excluding Misdemeanors And Summary Offenses, Which Has Not Been Annulled, Expunged Or Sealed By The Court? _____ Yes _____ No (If Yes, Describe In Full):

Have You Ever Received Workman’s Compensation Or Disability Income Payments? _____ Yes _____ No (If Yes, Describe):

Have You Physical Defects That Preclude You From Performing Certain Jobs? _____ Yes _____ No (If Yes, Describe Limitation):

EMPLOYMENT

Please Give Accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Company Name:

Telephone:

Address:

Employed (State Month And Year)

FROM

TO

Supervisor:

Start Pay:

Last Pay:

Job Title & Describe Your Work:

Reason For Leaving

May We Contact This Employer Listed Above? And If Not, Why?

Company Name:

Telephone:

Address:

Employed (State Month And Year)

FROM

TO

Supervisor:

Start Pay:

LAST Pay:

Job Title & Describe Your Work:

Reason For Leaving

May We Contact This Employer Listed Above? And If Not, Why?

Company Name:

Telephone:

Address:

Employed (State Month And Year)

FROM

TO

Supervisor:

Start Pay:

LAST Pay:

Job Title & Describe Your Work:

Reason For Leaving

May We Contact This Employer Listed Above? And If Not, Why?

MILITAR Y

Complete This Section If You Served In The U.S. Armed Forces

Branch of Service:

DUTIES & SPECIAL TRAINING:

PERIOD OF ACTIVE DUTY: From To

RANK AT DISCHARGE:

DATE OF FINAL DISCHARGE:

The information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or emission of facet on this application may result in my dismissal.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

If you decide to engage an investigative consumer-reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.

_____________________________ Date ______________________________________________Signature