Application for Employment

Applicant Information

Your Full Name

Present Address

Permanent Address (if different from present address)

Employment Desired

Personal Information

How did you hear about our company and this job opening?

Have you ever applied to or worked for Cuppa Tahoe before? YesNo

Why are you applying for work at Cuppa Tahoe?

Employment Application

If hired, would you have reliable means of transportation to and from work? YesNo

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum age.) YesNo

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable acccommodations? YesNo If no, describe the functions that cannot be performed.

(note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, skill, and agility tests.)

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

Education, Training, and Experience

High School

Did you Graduate? YesNo

College/University

Did you Graduate? YesNo

Vocational/Business

Did you Graduate? YesNo

Health Care Training

Did you Graduate? YesNo

Employment History

List below all present and past employment starting with your most recent employer (last five years sufficient).

Employer 1

Dates of Employment

Start Date End Date

Your Position and Duties Reason for Leaving

May we contact this employer for reference? YesNo

Employer 2

Dates of Employment

Start Date End Date

Your Position and Duties Reason for Leaving

May we contact this employer for reference? YesNo

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

Reference 1

Reference 2

Reference 3

Please Read Carefully, Check Each Paragraph and Sign Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize Cuppa Tahoe to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice or such disclosure. In addition, I hereby release Cuppa Tahoe, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I understand nothing contained in the application, or conveyed during any interview which may be granted or during employment, if hired, is inteded to create an employment contract between me and Cuppa Tahoe. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at anytime, with or without prior notice, at the option of either myself or Cuppa Tahoe, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Cuppa Tahoe's designated representative. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and complete the required employment eligibility verification document form upon hire.

Cuppa Tahoe will consider qualified applicants, including those with criminal histories, in a manner consistent with the state and local "Fair Chance" laws.

Full Name