Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home

(###)

###

####

Cell *

(###)

###

####

Do you have the legal right to remain and work in the United States?

Yes

No

What prompted you to work here? (Check all that applies)

I'm a customer

Friend/Relative

Employee Referral

Live in Neighborhood

Person to be notified in case of emergency

First Name

Last Name

Home

(###)

###

####

Cell

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of schedule desired

Part Time

Full Time

While working here, do you plan to

Work somewhere else

Attend school

Can you commit to at least 6 months of working here?

Yes

No

Highest Year Completed

9

10

11

12

Diploma?

Yes

No

Highest Year Completed

1

2

3

4

Degree?

Yes

No

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Under the guidelines of federal law, if hired, you are required to firnish documentation to show proof of identity and legal authorization to work in the United States. If hired, before you can start work you will need to submit a copy of your social security card* (authorization to work) and a copy of one of the following documents verifying proof of identity:

Drivers license or state issued ID card

School ID card with photo

ID card issued by Federal, State or local government containing a photo

Unexpired foreign passport with employment authorization

Current I.N.S. forms with employment authorization stamp (list A, I-9 form)

Original or certified copy of a US birth certifigate

Please confirm that all information above is accurate and that, if hired, the first month will be a trial period, after which time, Management can decide not to retain the person due to reason of incompatibility, without any legal recourse to Sencha Tea Bar. Training and orientation session is required. You will be required to sign a confidentiality and non-disclosure agreement.

Yes, I agree

No

Date

MM

DD

YYYY