Date of completion:

______ / _______ / ______

Employment Application
An Equal Opportunity Employer-
Kountry Kitchen is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for
employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodations in the application and/or
interview process should notify a representative of Kountry Kitchen.

PLEASE print CLEARLY and fill out ALL SECTIONS or APPLICATION will NOT be CONSIDERED.

APPLICANT INFORMATION What days and hours are

.
Name: __________________________________________ you available for work?

Home Phone: __________________________________________ [ ] MON ______________

Address: ___________________________________________ [ ] TUES _______________

___________________________________________ [ ] WED ______________

City / State: ___________________________________________ [ ] THURS _____________

Employment Position [ ] FRI ________________

Position(s) apply for: _____________________________________ [ ] SAT _______________

Are you applying for: Full Time [ ] or Part Time [ ] [ ] SUN _______________

If hired, on what date can you start working? _______/_______/_______

Can you work weekends? [ ] YES | [ ] NO Can you work evenings? [ ] YES | [ ] NO
Are you available to work overtime? [ ] YES | [ ] NO Salary desired: $ _________________
Personal Information
Have you ever applied to / worked for Kountry Kitchen before? [ ] YES | [ ] NO
If yes, please explain (include date): ____________________________________________________________
Do you have any friends, relatives, or acquaintances working for Kountry Kitchen? [ ] YES | [ ] NO
If yes, state name and relationship: _____________________________________________________________
If hired, would you have transportation to and from work? [ ] YES | [ ] NO
Are you over the age of 18? [ ] YES | [ ] NO
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United
States? [ ] YES | [ ] NO
If hired, are you willing to submit to and pass a controlled substance test? [ ] YES | [ ] NO
Are you able to perform the essential functions of the job for which you are applying, either with /without reasonable
accommodation? [ ] YES | [ ] NO If no, state what: ________________________________
Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ] YES | [ ] NO
If yes, please describe the crime – state nature of the crime(s), when and where convicted and disposition of the case. :
_________________________________________________________________________________________
_____________________________________________________________________________________________________________
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the
offense, including and significant details that affect the descriptions of the event, and the surrounding circumstances and the relevance of the offense
to the position(s) applied for may, however, be considered.)
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Education, Training, and Experience
High School College / University
Name: ________________________________ Name: ________________________________
Address: _________________________________ Address: _________________________________
_________________________________ _________________________________
City / State: _________________________________ City / State: _________________________________
Did you graduate? [ ] YES | [ ] NO Did you graduate? [ ] YES | [ ] NO
Year completed (when): ______________________ Year completed (when): _______________________

Additional/Vocational School Additional Information

Name: ________________________________ Do you speak, write or understand any foreign
language? [ ] YES | [ ] NO
Address: _________________________________
If yes, describe which language and how much you
_________________________________
know. _____________________________________
City / State: _________________________________
___________________________________________
Did you graduate? [ ] YES | [ ] NO
Notes: _____________________________________
Year completed (when): _______________________
____________________________________________

Employment History
Are you currently employed? [ ] YES | [ ] NO If yes, may we contact your employer? [ ] YES | [ ] NO
Be l o w , p l e a se d e sc r i b e t h e p a st a n d p r e se n t e mp l o y me n t p o si t i o n s, d a t i n g b a c k f i ve ye a r s. Pl e a se a c c o u n t f o r a l l
p e r i o d s o f u n e mp l o yme n t . E ve n i f yo u a t t a c h e d a re su me , t h i s se c t i o n mu st b e c o mp l e t e d .
Name of Employer: _________________________________ Business Type: _________________________
Telephone Number: ________________________________ Name of Supervisor: ___________________________
Address: _________________________________________________________________________________________
Date of Employment: ______________________________________________________________________________
Position & Duties: _________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________
May we contact this employer for references? [ ] YES | [ ] NO
Name of Employer: _________________________________ Business Type: _________________________
Telephone Number: ________________________________ Name of Supervisor: ___________________________
Address: _________________________________________________________________________________________
Date of Employment: ______________________________________________________________________________
Position & Duties: _________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________
May we contact this employer for references? [ ] YES | [ ] NO
Name of Employer: _________________________________ Business Type: _________________________
Telephone Number: ________________________________ Name of Supervisor: ___________________________
Address: _________________________________________________________________________________________
Date of Employment: ______________________________________________________________________________
Position & Duties: _________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________
May we contact this employer for references? [ ] YES | [ ] NO

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References

List below three persons who have knowledge of your work performance within the last four(4) years. Please include
professional reference only.
Name – First, Last: ____________________________________________________________
Telephone Number: ____________________________________________________________
Address: ____________________________________________________________
City, State, Zip: ____________________________________________________________
Occupation: ____________________________________________________________
Number of Years Acquainted: ______________________________________________________

Name – First, Last: ____________________________________________________________

Telephone Number: ____________________________________________________________
Address: ____________________________________________________________
City, State, Zip: ____________________________________________________________
Occupation: ____________________________________________________________
Number of Years Acquainted: ______________________________________________________

Name – First, Last: ____________________________________________________________

Telephone Number: ____________________________________________________________
Address: ____________________________________________________________
City, State, Zip: ____________________________________________________________
Occupation: ____________________________________________________________
Number of Years Acquainted: ______________________________________________________

Please Read and Sign Below.

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the
fact that the answers given by me are true and correct to the best of my knowledge and ability.
I understand that any omission (including any misstatement) of material fact on this application or on any document used to
secure can be grounds for rejection of application or, if I am employed by this company, term for my immediate expulsion from the
company.
I permit the company to examine my references, record of employment, education record, and any other information I have
provided. I authorize the references I have listed to disclose any information related to my work record and my professional
experiences with them, without giving me prior of such disclosure. In addition, I release the company, my former employer’s & all
other persons, corporations, partnerships, and associations from any & all claims, demands or liabilities arising out of or in any way
related to such examination or revelation.

I UNDERSTAND THAT THIS DOES NOT GUARANTEE OR SECURE EMPLOYEMENT.

This is for an application, not a guarantee of a job.
BY SIGNING BELOW, I UNDERSTAND AND AGREE TO ALL WRITTEN ABOVE.

Applicant Signature: ____________________________________________ Date: _________________________

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