Saint Henry Dairy Dream

Employment Application

Mail this application to PO Box 436 St. Henry , OH 45883 or e-mail it to

Full Name: ______

Street Address: ______

City: ______State: ______Zip: ______

Email Address: ______

Home Phone #:______Your Cell Phone # ______

High School Attending/Attended: ______Highest Grade Completed: ______

Number of Days Absent: ______Number of Days Tardy: ______Your Age: ______

Math Grade: ______Overall GPA: ______

School Activities/Sports: ______

Chores you do at home: ______

Are you employed now? Yes No If Yes, where: ______

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Yes No

Can you work evenings after school? Yes No

If yes, which shift(s)? 9-12 12-4pm 4-7pm 7-10pm (circle all that apply)

Can you work until 10:30pm Friday and Saturday? Yes No

Can you work until 9:30pm Sunday thru Thursday? Yes No

Date you are available to start: ______

During School Months What Hours Are You Available (List Below): Desired Hours Per Week? ______

Hours / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
From: (Start)
To: (End)

During Summer Months What Hours Are You Available (List Below): Desired Hours Per Week? ______

Hours / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
From: (Start)
To: (End)

Saint Henry Dairy Dream

Employment Application

How far away do you live from SH Dairy Dream? ______

Do you have a legal driver’s license? ______

How will you get to work? ______

Who do you know who works here? ______

References: Give the names of three persons not related to you, whom you have known at least one year.

Name / Address / Business / Years Acquainted
1.
2.
3.

All applicants MUST have a Social Security Card & a work permit (if under age 16).

You are required by law to inform the business owners if you or anyone in your household has been diagnosed with Salmonella, Shigella, E Coli and / or Hepatitis.

Have you ever been diagnosed with any one of these? Yes No

Do you smoke? Yes No

"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT

IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I

AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.

IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT

MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY

TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY

EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I

UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S OWNERS, AND THEN ONLY WHEN IN WRONG AND SIGNED

BY THE OWNERS, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME,

OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

DATE: ______SIGNATURE: ______

DO NOT WRITE BELOW THIS LINE

INTERVIEWED BY: DATE:______

REMARKS:______

NEATNESS:______ABILITY:______

HIRED Yes No WHAT POSITION:______

SALARY/WAGE:______DATE REPORTING TO WORK:______