APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

PLEASE COMPLETE ALL PAGES.

DATE __________________________

Name ______________________________________________________________________________

                        Last                                                                 First                                                                Middle                                                            Maiden

Present address _______________________________________________________________________

                                                                        Number                                                          Street                                     City                 State               Zip

How long _______________

Social Security No. _____ –  _____  –   _____

Telephone (      )                   

Position applied for  (1)________________

and salary desired   (2) ________________

(Be specific)

Days/hours available to work

No Pref _____  Thur _______

Mon _______   Fri ________

Tue ________   Sat _______

Wed _______   Sun _______

How many hours can you work weekly? ______________   Can you work nights? ________________

Employment desired  qFULL-TIME ONLY             qPART-TIME ONLY            qFULL- OR PART-TIME

When available for work?________

____________________________________________________________________________________

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School

College

Bus. or Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? q No              q Yes

If yes, explain number of  conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. _______________

DO YOU HAVE A DRIVER’S LICENSE? q Yes q No

What is your means of transportation to work? ____________________________________________

Driver’s license
number _______________________  State of issue  _______        q Operator     q Commercial (CDL)     qChauffeur

Expiration date ________________

Have you had any accidents during the past three years?

How many? _____________

Have you had any moving violations during the past three years?

How Many? _____________

Please list two references other than relatives or previous employers.

Name ________________________________

Name ___________________________________

Position _______________________________

Position _________________________________

Company ______________________________

Company ________________________________

Address _______________________________

Address _________________________________

            ________________________________

            __________________________________

Telephone  (      )                                                

Telephone  (      )                                                     

An application form sometimes makes it difficult for an individual to adequately summarize a complete background.  Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying, or attach a resume.

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES?               q Yes q No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?              q Yes q No

Specialty ___________________________  Date Entered ___________  Discharge Date _________

Work Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name.  Attach additional sheets if necessary.

Name of employer
Address

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number

From

To

Start

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer
Address

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number

From

To

Start

Final

Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?     q Yes q No

Did you complete this application yourself   q Yes q No

If not, who did? ______________________________________________________________________

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Northampton Wines and Wine Café  (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company.  Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason.  If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application.  I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice.  I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.  I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living.  Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of applicant__________________________________________ Date: ___________________

This Company is an equal employment opportunity employer.  We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability.  We assure you that your opportunity for employment with this Company depends solely on your qualifications.

                Thank you for completing this application form and for your interest in our business.