CAPANNA

Coffee & Gelato

Application for employment

      Name (last name first):                                Social Security Number:

      Present Address:                            City                State             Zip Code

      Permanent Address:                       City                State             Zip Code

      Phone Number:                                        Referred By:

            (           )                                                                                                          

      Email address:                                                                                                   

      Are you 18 or Older?                  If No, How old are you?                               

      Position Desired:                  Date You Can Start:             Salary Desired:

      Are You Employed?            If so, may we inquire of your present employer?

      Yes            No                       Yes             No                 

      Ever applied to this company before?    Where?                   When?

      Yes            No                                                                                                         

      Which Store ar you applying for(Circle One)    Downtown         Coralville

      Education History     

                       Name and location of school   Years attended   Did you graduate?   Subjects studied

       High School                                                                                                                   

       College                                                                                                                             

     Trade School                                                                                                                   

     Subjects of special study/ research work or special training/skills:

     US Military or Naval Service:                          Rank:

     Former Employers (list last four employers, starting with most recent):

      1.  Name and address of Employer               Date:   (month/year)

                                                                              From                To                            

        Salary:          Position:            Reason For Leaving:

     2.                                                                      From                To                            

     3.                                                                      From                To                            

     Hours of Availability         Amount of Hours Desired:               Minimum:      

            Mon        Tue         Wed        Thurs        Fri        Sat        Sun

     References

     Please give the names of three persons not related to you, whom you have       

      known for at least one year:  

     Name:             Address:                       Business:                   Years Known:

    1.                                                                                                                            

    2.                                                                                                                            

    3.                                                                                                                            

    Authorization: “ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

Date:                           Signature                                                                              

Interviewed by:                                                                       Date: