Ciros Pizza Application Form – Fill Out and Use This PDF

Supervisor: ______________________________	Reference checked	Salary: _________Type(s) of job: ___________________________
Dates worked from: ____________to: _________	int.: ________	Reason for leaving: ______________________________________
EMPLOYMENT HISTORY
Company: ______________________________________________		Supervisor: _____________________________ Reference checked
Address: _______________________________________________		Dates worked from: _____________ to: _______ int: ____________
City/State/Zip: __________________________________________		Salary: ______________ Job description: _____________________
Telephone number: _______________________________________		Reason for leaving: _______________________________________
_______________________________________________________________________________________________________________________
PERSONAL REFERENCES
Name___________________________________________________		Name___________________________________________________
Address_________________________________________________		Address_________________________________________________
City/State/Zip____________________________________________		City/State/Zip____________________________________________
Telephone number: ________________________________________		Telephone number: ________________________________________

The Secretary of Health and Human Services has determined that certain diseases, including hepatitis A, salmonella, shigella, staphylococcus, streptococcus, giardia, E. coli and campylobacter may prevent you from serving food or handling food equipment in a sanitary or healthy fashion. An essential function of this job involves handling and serving food, food service equipment and utensils in a sanitary and healthy fashion. Is there any reason why you cannot perform the essential functions of this job? Yes______ No______ If Yes, describe in full:______________________________________________________________

During the past 7 years, have you ever been convicted of or plead guilty to a crime, excluding misdemeanors and traffic violations? Yes____ No_____

U.S. MILITARY

Branch of Service: ___________________ Date Entered: _____________ Date of Discharge__________ Highest Rank: ___________

Do you have service-related skills and experience application to civilian employment? Yes_____ No_____ If Yes, Describe________

I certify that I have read and fully completed both pages of this application and that the information contained on this application is correct to the best of my knowledge and understanding that any omission or erroneous information is grounds for dismissal in accordance with Ciro s Pizza Café policy. 2) I authorize the references listed on this application to give you any and all information concerning my pervious employment and pertinent information they may have, personal or otherwise and release all parties form all liabilities for any damages that may result from furnishing same to you. 3) I acknowledge that Ciro s Pizza Cafe reserves the right to amend to or modify the policies in its Handbook and other Ciro s Pizza Cafe policies at any time, without prior notices. These policies do not create any promise or contractual obligations between Ciro s Pizza Cafe and it employees. At Ciro s Pizza Cafe, my employment is at will. The means that I am free to terminate my employment at any time, for any reasons, with or without cause, and Ciro s Pizza Café retains the same rights.

Ciro s Pizza Café is an Affirmative Action and Equal Opportunity Employer. Various Federal, State and Local laws prohibit discrimination on account of race, color, religion, sex, age, national origin, disability, or veteran status. It is Ciro s Pizza Café policy to comply fully with these laws and applicable, and information required on this application will not be used for any purpose prohibited by law.

Signature: ______________________________________

Date: ________________________________