Bar Kada Avenue
2605 South Decatur Blvd Suite 120-122 Las Vegas, Nevada 89102
Ph: (702) Bar-Kada (227-5232)
Fax: (702) 754-2602
Email: [email protected]
Position applying for: ______________________________________________
A complete application consists of this completed form and your current resume (if any). Please type or print legibly
Personal
Today’s date ___________________________ Your date of birth _______________ (MM/DD/YY) ___________________
Name as it appears on your driver’s license ________________________________________________________________
Last
First
Middle
Maiden
Current address _____________________________________________________________________________________
Street
City
State
Zip
Permanent address ___________________________________________________________________________________
Street
City
State
Zip
Email address _____________________________________________
Phone Nos. with area code: Home ____________________ Daytime ____________________ Cell ____________________
Citizenship _____________________ If not US, are you a permanent resident of the US?  Yes  No
red upon arrival.)
Are you over the age of 18?
 Yes  No (Proof of age or work permit required) Age: _________________
Do you have a health card?
 Yes  No
if No, Will you be able to get one?
 Yes  No
Education
TYPE OF
SCHOOL
NAME OF SCHOOL
CITY & STATE
YEARS
COMPLETED
MAJOR & DEGREE
High School
Undergraduate
Graduate School
Sports / Activities / Club
____________________________________________________________________________________________________
Sports / Activities / Club
____________________________________________________________________________________________________
Bar Kada Avenue
2605 South Decatur Blvd Suite 120-122 Las Vegas, Nevada 89102
Ph: (702) Bar-Kada (227-5232)
Fax: (702) 754-2602
Email: [email protected]
Because Bar-Kada Avenue employees supervise and (sometimes) come in contact with minors, it is necessary for
us to ask for information about your criminal record (if any) and driving record, and verify this information with
corresponding authorities. See also the note at the bottom of the next page.
Criminal Record
Have you ever been convicted of a crime, other than traffic violations?
 Yes  No
If yes, explain nature and location of offense(s) leading to conviction(s), how recently such offense(s) was/were committed,
sentence(s) imposed, and type(s) of rehabilitation. ___________________________________________________________
___________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Driving Record
Driver’s license number ___________________________ State of issue _______ Expiration date _____________________
Availability
Hours available to work per week: _______________
 Part Time
What type of employment are you seeking?
M
T
Desired Salary per hour: _________________
W
T
 Full Time
F
 Seasonal
S
 Temporary
S
From
To
Date available to start work? _______________
Method of Transportation: __________________________________
Are you able to meet the attendance requirement of the position?  Yes  No if No, why? ________________________
__________________________________________________________________________________________________
Are you currently employed?  Yes  No If yes, where? __________________________________________________
Bar Kada Avenue
2605 South Decatur Blvd Suite 120-122 Las Vegas, Nevada 89102
Ph: (702) Bar-Kada (227-5232)
Fax: (702) 754-2602
Email: [email protected]
Professional Experience
Company: ___________________________________
Supervisor: __________________________________
Contact: _____________________________________
Hourly Wage: ___________________
Employment dates
Weekly Wage: __________________
From: ____________
Monthly Wage: __________________
To: ______________
Briefly describe your title and duties: _______________________________________________________________________
____________________________________________________________________________________________________
Reason for leaving:_____________________________________________________________________________________
____________________________________________________________________________________________________
Company: ___________________________________
Hourly Wage: ___________________
Employment dates
Weekly Wage: __________________
From: ____________
Monthly Wage: __________________
To: ______________
Supervisor: __________________________________
Contact: _____________________________________
Briefly describe your title and duties: _______________________________________________________________________
____________________________________________________________________________________________________
Reason for leaving:_____________________________________________________________________________________
____________________________________________________________________________________________________
References
Name: __________________________________________
Name: __________________________________________
Relationship: _____________________________________
Relationship: _____________________________________
Position: _________________________________________
Position: _________________________________________
Employer: ________________________________________
Employer: ________________________________________
Address: _________________________________________
Address: _________________________________________
Year(s) Known: ___________________________________
Year(s) Known: ___________________________________
Phone: __________________________________________
Phone: __________________________________________
Email: ___________________________________________
Email: ___________________________________________
Bar Kada Avenue
2605 South Decatur Blvd Suite 120-122 Las Vegas, Nevada 89102
Ph: (702) Bar-Kada (227-5232)
Fax: (702) 754-2602
Email: [email protected]
Emergency Contact
First Emergency Contact
Name: _____________________________________________________
Last
First
Phone: ( _____ ) - _______ - __________
Middle
Address: ________________________________________ City: __________ State: ___________ Zip Code: _______
Email address: ____________________________________
Relation: _______________________________________
Second Emergency Contact
Name: _____________________________________________________
Last
First
Phone: ( _____ ) - _______ - __________
Middle
Address: ________________________________________ City: __________ State: ___________ Zip Code: _______
Email address: ____________________________________
Relation: _______________________________________
Accommodation of Disabilities
A job description has been provided to you. Indicate if you are physically able to perform the essential functions of the job for
which you have applied  Yes  No.
If you answered “No”, please identify those job functions that you cannot perform. If a reasonable accommodation is required
to enable you to perform the job properly and safely, please describe:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Consent Agreement and Publicity Release
In consideration of my prospective employment by Bar-Kada Avenue:
I authorize investigation of all statements contained in this form, including my criminal record and
driving record. 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 Bar-Kada Avenue permission to
contact my previous or current schools or employers, references, and others, and hereby release from
any liability as a result of such contact.
Print Name ________________________________________
Signature __________________________________________ Date: ___________________
Note: State and Federal laws require employers to perform criminal and driving background checks on their
employees and volunteers who work with minors. Bar-Kada Avenue’s use of background check information is
regulated by law.
Bar-Kada Avenue is an equal opportunity employer. We adhere to a policy of making employment decisions
without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability.