Employment – The Country Place Restaurant

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First Name

Last Name

Address 1

Address 2

City

Zip / Post Code

Daytime Phone

Evening Phone

Email *

Position you are applying for

Are you able to work

Full Time
Part Time

How many shifts would you prefer

Are there any days/nights you can't work:

High School

College

Employer 1 - Name/Address/Phone

Employer 1 - Dates Employed

Employer 1 - Job Performed

Employer 1 - Reason for Leaving

Employer 2 - Name/Address/Phone

Employer 2 - Dates Employed

Employer 2 - Job Performed

Employer 2 - Reason for Leaving

Employer 3 - Name/Address/Phone

Employer 3 - Dates Employed

Employer 3 - Job Performed

Employer 3 - Reason for Leaving

Employer 4 - Name/Address/Phone

Employer 4 - Dates Employed

Employer 4 - Job Performed

Employer 4 - Reason for Leaving

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