tomodachiemployment .pdf

An equal opportunity employer
156 Rosedale Center
Roseville, MN 55113
651-631-1777

Date: _________

Contact Number: _________________________

Name: _____________________________________

Email: _________________________

Present Address: _____________________________________________________________
- Are you over 18 years of age?

Yes

No

- Can you submit a birth certificate or other proof of age or citizenship?
- Are you looking for:

Full-time employment

Salary Desired: ____________________

Yes

No

Part-time employment

If hired, date available to work: _______________

Hours

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

AM

-  

-  

-  

-  

-  

-  

-  

PM

-  

-  

-  

-  

-  

-  

-  

EDUCATION

School Name and Address

Years Attended

Graduated

High School

Yes No

College

Yes No

Trade

Yes No

Other

Yes No

Introduce yourself:

Course or Major

Please complete the following in detail, including all dates, places, and persons involved:
Month and Year
Latest Employer First

Name, Address, and Phone of Employer

Salary

Position

Reason for
Leaving

From _____ to _____

From _____ to _____

From _____ to _____

From _____ to _____

References
Name: _______________ Address: ________________________ Length of time known: __
Name: _______________ Address: ________________________ Length of time known: __
Name: _______________ Address: ________________________ Length of time known: __
- Do you have a physical condition that limits you from performing your job?

Yes

No

If yes, please explain: _________________________________________________________
- Do you have a valid drivers’ license?

Yes

No

State: ________________________

- Would you agree to be placed under a 30-day employment waiver?

Yes

No

Please answer the following:
(1) Have you ever been bonded? _____
(2) Have you ever been fired, discharged, or asked to resign from any job? _____
(3) Have you ever been convicted of a crime? _____
(4) Have you ever been convicted of a crime under a different name? _____
If yes, please explain: ________________________________________________________________________

I certify that all statements on this application are true, and I hereby authorize investigation of all my
statements. I understand and agree that falsification of facts on this application is cause for dismissal.

Signature: ____________________________________ Date: ______________
Do not write below this line
Supervisor:
References

Date:
Notes