Flippin Pizza Application Form – Fill Out and Use This PDF

.

APPLICATION FOR EMPLOYMENT

Position Desired:

[

] Part time [

] Full time Date___________________________

Name

_

(Print)

Last

First

Middle

Present

How long have

Address

you lived there? ______________________

Street and Number

City

State

Zip Code

Years

Months

Previous

How long did

Address

you live there? ________________________

Street and Number

City

State

Zip Code

Years

Months

Telephone No.

Have you ever worked for Flippin’ Pizza, LLC before?

[

] Yes [ ] No

If yes, please give dates and position:__________________________________________________________________

NOTE: Answering "Yes" to either of the following two questions does not constitute an automatic bar to employment. Factors such as the date of the offense, seriousness and nature of the violation, and rehabilitation may be taken into account.

Have you ever pled guilty or "no contest" to, or been convicted of, a misdemeanor or felony? [ ] Yes [ ] No If yes, please give the date(s) and details:

________________________________________________________________________________________________

Have you been arrested for any matters for which you currently are out on bail or on your own recognizance pending trial? [ ] Yes [ ] No

If yes, please give the date(s) and details:

________________________________________________________________________________________________

RECORD OF PREVIOUS EMPLOYMENT

Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including relevant military service and any period of unemployment. If self-employed, give firm name and supply business references. [Add additional page if necessary]

Present or Last Employer	Employed	Pay	Your Title or Position	Exact Reason for Leaving
________________________
Address	________	$_______	_____________________
________________________
	From	Start
City, State, Zip Code
	(mo/yr)	$_______	_____________________
________________________
		Final	Name and Title of
Telephone
	________		Last Supervisor
	To (mo/yr)

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Have you ever been terminated or asked to resign from any job? [ ] Yes [ ] No

If yes, please explain circumstances:

___________________________________________________________________________________________________________

Please explain fully any gaps in your employment history:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

May we contact your current employer? [ ] Yes [ ] No. If No, please explain:

___________________________________________________________________________________________________________

Please indicate any actual experience, special training and qualifications that you have which you feel are relevant to the position for which you are applying.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Have you ever used another name? [ ] Yes [ ] No Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record? If yes, please explain:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

If hired, can you furnish proof that you are over 18 years of age? [ ] Yes [ ] No

Are you capable of satisfactorily performing the essential job duties required of the position for which you are applying with or without a reasonable accommodation for a disability?

[ ] Yes [ ] No

Do you have adequate transportation to and from work? [ ] Yes [ ] No

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Elementary:	4 5 6 7	8
High School:	9 10 11	12
College/University:	1 2 3 4
Graduate/Professional:	1 2 3 4
Trade or Correspondence:
Other:

PERSONAL REFERENCES

Please list persons who know you well -- not previous employers or relatives

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE.

______________________	______________________________________________________
Date	Signature of Applicant

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APPLICANT'S STATEMENT & AGREEMENT

In the event of my employment to a position at Flippin’ Pizza, LLC (“Company”), I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality and honesty tests, prior to and during my employment, to the extent permitted by law. I understand that should I decline to sign this consent or take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed.

I further understand that the Company may obtain Public Records about me as part of a background investigation and that, although I am not required to do so, I may waive my right to receive a copy of such Public Records by checking the box to the right [ ].

I further understand that the Company may contact my previous employers. I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby waive any rights or claims I have or may have against the Company and against my former employers, their agents, employees, and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the Company with any pertinent information they may have regarding myself.

I hereby state that all the information that I have provided on this application or any other documents completed in connection with my employment, and in any interview is true and accurate. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any information provided to the Company is found to be false or incomplete in any respect, I may be dismissed.

I further agree and acknowledge that the Company and I will utilize binding arbitration to resolve all disputes that may arise out of the hiring process, including but not limited to my application for employment, the Company’s decision to hire me or not, and/or any conduct by the Company or me related to the Company’s decision to hire me or not. Both the Company and I agree that any such claim, dispute, and/or contr oversy that either I

may have against the Company (or its owners, directors, officers, managers, employees, agents, and parties affiliated with its employee benefit and health plans) or the Company may have against me shall be submitted to and determined exclusively by binding arbitration under the Federal Arbitration Act, to the extent permitted by law, in conformity with the procedures of the State Arbitration Code. Included within the scope of this Agreement are all disputes, whether based on tort, contract, statute (including, but not limited to, any claims of discrimination and harassment, whether they be based on the state Civil Rights Act, Title VII of the Civil Rights Act of 1964, as amended, or any other state or federal law or

regulation), equitable law, or otherwise, with exception of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under the State Workers’ Compensation Law or as otherwise required by

state or federal law. However, nothing herein shall prevent me from filing and pursuing proceedings before the state Commission on Human Relations, or the United States Equal Employment Opportunity Commission (although if I choose to pursue a claim following the exhaustion of such administrative remedies, that claim would be subject to the provisions of this Agreement). The arbitration will be held at a mutually convenient location within the county of the location where the application for employment was submitted. In addition to any other requirements imposed by law, the arbitrator selected shall be a retired State Circuit Court Judge, or otherwise qualified individual to whom the parties mutually agree, and shall be subject to disqualification on the same grounds as would apply to a judge of such court. To the extent applicable in civil actions in U.S. District Court, the following shall apply and be observed: all rules of pleading (including the right of demurrer), all rules of evidence, all rights to resolution of the dispute by means of motions for summary judgment, and judgment on the pleadings. Resolution of the dispute shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including but not limited to, notions of "just cause") other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration

proceedings are privileged in accordance with all applicable State law. As reasonably required to allow full use and benefit of this agreement's modifications to the State Arbitration Code’s procedures, the arbitrator shall extend the times set by Federal Arbitration Act for the giving of notices and setting of hearings. Awards shall include the arbitrator's written reasoned opinion and the arbitrator’s decision will b e final and binding. A party’s right to appeal the decision is limited to grounds provided under applicable federal or state law. Each party shall be responsible for its own attorneys’ fees unless otherwise provided for under federal or state law. In addition, the arbitrator’s fees shall be paid f or in accordance with

applicable federal or state law. I understand and agree to this binding arbitration provision, and both I and the Company give up our right to trial by jury of any claim I or the Company may have against each other pursuant to this agreement.

If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by either the Company (employer) or me at any time and for any lawful reason whatsoever, with or without cause and with or without notice. In addition, I also agree that, if hired, the Company at its sole discretion may alter the terms and conditions of my employment, with the exception of my at-will status, which may only be altered through a written signed statement by the President of the Company.

This is the entire agreement between the Company and me regarding the length and nature of my employment and the resolution of any dispute that may arise out of the hiring process, and this agreement supersedes any and all prior agreements regarding these issues. It is further agreed and understood that any agreement contrary to the foregoing must be entered into, in writing, by the President of the Company. No supervisor or representative of the Company, other than its President, has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing. Oral representations made before or after you are hired do not alter this Agreement.

If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable.

IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE ASK A COMPANY REPRESENTATIVE BEFORE SIGNING. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE SAME.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT & AGREEMENT.

_____________________________________	____________________
Signature of Applicant	Date

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