DATE______

APPLICATION FOR EMPLOYMENT

Top Pot Doughnuts is an equal opportunity employer. We have a policy of non-discrimination and will provide employment opportunities to all qualified individuals regardless of race, color, age, sex, religion, national origin, physical or mental disabilities, sexual orientation, marital status or any other characteristic protected under federal, state or local law.

PERSONAL INFORMATION

NAME ______PHONE______
(LAST) (FIRST) ( MIDDLE)
ADDRESS______
(STREET) (CITY) (STATE) (ZIP)
ALT. PHONE______EMAIL______
ARE YOU 18 YEARS OF AGE OR OLDER? YES or NO REFERRED BY______
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S? YES or NO
(ALL NEW HIRES WILL BE REQUIRED TO PROVIDE ACCEPTABLE DOCUMENTATION)

EMPLOYMENT DESIRED

POSITION DESIRED______LOCATION______
DATE YOU CAN START______SALARY DESIRED______
HAVE YOU EVER WORKED FOR TOP POT?______IF YES, WHEN?______
DO YOU HAVE ANY RELATIVES WORKING FOR TOP POT? ______
IF SO, WHICH LOCATION? ______
DO YOU HAVE A NON-COMPETE, NON-DISCLOSURE, OR OTHER AGREEMENT THAT MIGHT RESTRICT YOUR EMPLOYMENT
WITH US? YES or NO

AVAILABILITY

SPECIFY AVAILABLE HOURS FOR EACH DAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY / SUNDAY

EDUCATION

Name and Address / Circle Last Year Completed / Did You Graduate? / Subjects Studied
HIGH SCHOOL / 1 2 3 4 / Y N
COLLEGE, TRADE OR
BUSINESS SCHOOL / 1 2 3 4 / Y N
POST COLLEGE / 1 2 3 4 / Y N

WORK HISTORY

LIST BELOW LAST FOUR EMPLOYERS STARTING WITH MOST RECENT OR CURRENT EMPLOYER
If currently employed, may we contact your present employer? YES or NO
FROM / NAME AND ADDRESS / SALARY / POSITION / REASON FOR LEAVING
TO
JOB DESCRIPTION
SUPERVISOR / PHONE NUMBER
FROM / NAME AND ADDRESS / SALARY / POSITION / REASON FOR LEAVING
TO
JOB DESCRIPTION
SUPERVISOR / PHONE NUMBER
FROM / NAME AND ADDRESS / SALARY / POSITION / REASON FOR LEAVING
TO
JOB DESCRIPTION
SUPERVISOR / PHONE NUMBER
FROM / NAME AND ADDRESS / SALARY / POSITION / REASON FOR LEAVING
TO
JOB DESCRIPTION
SUPERVISOR / PHONE NUMBER

PROFESSIONAL REFERENCES

LIST THE NAMES OF THREE PEOPLE, OTHER THAN RELATIVES, WHO CAN SPEAK TO YOUR WORK EXPERIENCE.
NAME / PHONE NUMBER / BUSINESS / YEARS KNOWN

AUTHORIZATION

I authorize Top Pot Doughnuts to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, and references. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including Top Pot Doughnuts and Top Pot Authorized Representatives) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising our of furnishing any information. If employed, I release Top Pot Doughnuts from any liability for future references it may provide regarding my work history with Top Pot Doughnuts.

I understand and agree that no representative of the company has any authority to enter into any agreement for any specified period of time and that my employment is at will and can be terminated at any time by me or Top Pot Doughnuts without prior notice for any reason. Due to the large number of applications received, I understand that Top Pot Doughnuts cannot guarantee that my application will be considered for any or all open positions or that my application will be considered for any specific time.

I certify that the facts contained in this application are true and complete to the best of my knowledge and that any falsification, omission or misrepresentation of facts on this application or any other document may lead to my immediate dismissal no matter how they are discovered.

I have read and reviewed the above information and agree with all of the statements on this application.

______

SIGNATURE OF APPLICANT DATE

Revised 9/07/09