Mr. B's Bistro : Contact Us : Employment Info

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment
on any basis including race, creed, color, age, sex, religion, national origin or physical disability.

Personal Information
Date:
Date of Birth:	(MM/DD/YYYY)
Full Name:
E-mail Address:
Present Address:

Permanent Address:

Phone:
Name and Department of Any Relatives Already Employed by this Company:

Referred By:

Employment Desired
Position:
Date you can start:
Salary Desired:
Are you employed now?	Yes \| No
If so may we inquire of your present employer	Yes \| No
Ever Applied to a Brennan-owned restaurant before?	Yes \| No
Where:
When:

Education
School	Name and Location of School	Years	Graduate?	Major and/or Degree(s)
Grammar School
High School
College
Other Training

Physical Record
Do you have any physical condition which might limit your ability to fully perform the job you applied for or a job into which you might be placed?
Do you have any contagious diseases?
If yes, explain briefly:

Have you ever been diagnosed as having an occupational injury or disease which might limit your ability to fully perform the job you applied for or a job into which you might be placed?
If yes, explain briefly:

Miscellaneous
Have you ever been convicted of a felony?
If yes, explain briefly:

Are you a citizen of the United States?
If not what is your green card Number
Do you have the right to work in the United States

Work History

List below last four employers, starting with your present job.

Present Employer
From:	To:
Employer's Name:
Employer's Address:
Supervisor's Name
Job or jobs held:
Hourly or weekly salary: $
Reason for leaving:

Next Employer
From:	To:
Employer's Name:
Employer's Address:
Supervisor's Name
Job or jobs held:
Hourly or weekly salary: $
Reason for leaving:

Next Employer
From:	To:
Employer's Name:
Employer's Address:
Supervisor's Name
Job or jobs held:
Hourly or weekly salary: $
Reason for leaving:

Next Employer
From:	To:
Employer's Name:
Employer's Address:
Supervisor's Name
Job or jobs held:
Hourly or weekly salary: $
Reason for leaving:

By submitting this form you agree to the following:

I certify that the information provided in this application is accurate and complete. I realize that providing false information may disqualify me from employment. I also realize that this application will be investigated. I recognize that discovery of incomplete or false information is a serious matter and even if I am hired, such discovery may lead to my discharge.
I authorize investigation of all statements contained in this application.
I agree to allow my previous employers to discuss with representatives of your company the circumstances of my employment as well as the circumstances of my termination from employment with those previous employers.
I realize that this application will remain active for 31 days from the date of application and that at the end of that period I must re-apply to express a continuing interest in employment.

I have read and understand the importance of these provisions and willingly agree to them.

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