The Stage on Broadway

Last Name

First Name

Middle Name

Present Address

Street

City

State

Zip

Permanent Address

Street

City

State

Zip

Home Phone

Cell Phone

Have you been convicted of a felony or misdemeanor within the last 5 years?

Yes No

Describe

Do you smoke cigarettes or use tobacco products?

Yes No

Employment Desired

Position

Date you can start

Salary Desired

Are you employed now?

If so, may we inquire of your present employer?

Ever applied to this company before?

Where?

When?

Education

High School Name

High School Location

No. of Years Attended

Did you Graduate

Year Graduate

College Name

College Location

No. of Years Attended

Did you Graduate

Year Graduate

Trade, Business or correspondence Name

Trade, Business or correspondence Location

No. of Years Attended

Did you Graduate

Year Graduate

General

Subjects of Special Study, Interest, Hobbies

U.S Millitary or Naval Service

Rank

Present Membership in National Guard or Reserves

Former Employers(list below last four employers, Starting with last one first)

Date From

Date To

Name & Address Employer

Salary

Position

Reason of Leaving

Date From

Date To

Name & Address Employer

Salary

Position

Reason of Leaving

Date From

Date To

Name & Address Employer

Salary

Position

Reason of Leaving

Date From

Date To

Name & Address Employer

Salary

Position

Reason of Leaving

Reference(Give the Names of Three persons not related to you, Whom you have known at least one year)

Name

Address

Business

Year Acquainted

Name

Address

Business

Year Acquainted

Name

Address

Business

Year Acquainted

Name

Address

Business

Year Acquainted

Physical Record

Do you have any Physical limitations that preclude you from performing any work for which you are being considered?

Yes No

If yes, What can be done to accommodate your limitation?

Please Describe

In case of Emergency notify

Name

Address

Phone No.

I certify that the facts contained in this application are true and complete to the best of the knowledge and understand that, if employed, false statements in this application will be grounds for dismissal. i understand and agree that if hired, my employment is for no definite period and that either i or The Stage on Broadway may terminate my employment at any time with o without cause. I hereby authorize The Stage on Broadway to conduct background checks to determine my suitability for employment. Such background checks may include work history, criminal and financial records

Date

Signature