Bar Kada Avenue
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.
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