IF HIRED, FEDERAL LAW REQUIRES YOU TO FURNISH PROOF SHOWING IDENTITY AND THAT YOU ARE LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES.

Store location; Newton Falls or Lordstown ( circle desired location(s))

Name;

first middle last

Address;

city state zip

If under 18 years old; birthdate & age; student; Y N present grade

Ever worked at Dairy Queen? Y N if so, where?

Phone number with area code; social security #

ARE YOU LEGALLY ABLE TO WORK IN THE USA?

DO YOU HAVE TRANSPORTATION TO AND FROM WORK?

PLEASE CIRCLE DAYS AVAILABLE TO WORK; MON.; TUES., WED, THUR, FRI, SAT, SUN

ARE YOU SEEKING FULL TIME OR PART TIME ( CIRCLE DESIRED)

LIST HOURS AVAILABLE TO WORK;

SCHOOL ATTENDED GRADUATED; Y N

EXTRA ACTIVITIES AND SPORTS;

PRESENT OR MOST RECENT JOB;

DATES WORKED SUPERVISOR;

SALARY; REASON FOR LEAVING;

ANY OTHER JOB THAT YOU HAVE HAD; ANSWER SAME AS ABOVE; USE BACK IF NEEDED

PERSONAL REFERENCES;

I hereby authorize any person(s) or concern and all information including personal character habits, work records and skills or any other pertinent information in their possession without any liability to damages whatsoever on account of furnishing such information. I understand that if hired, any misstatements on this form are grounds for immediate discharge.

SIGNATURE; DATE;