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Brookhaven / Buckhead / Dunwoody / Farragut / Knoxville

Mellow Mushroom
Employment Application

Name:
 *
Email:
 *
Address:
Phone 1:
 *
Phone 2:
Date of Birth:
 *
Driver’s License Number:
State:
Position(s) Applied For:
Location you are applying to?
Type of employment desired
 Full Time Part Time Temporary
Shift Desired:
 Day    Evening    Night
Hours Available:
Have you been convicted of a felony in the last seven years?
 Yes No

If Yes, Please Explain:

Educational Background:

School Name Years Completed Major Minor

Personal References (Name, Address, & Phone):

Employment History:

List your three most recent employers, beginning with your current. Please explain any gaps in employment in comments section below.

1. Most Recent Employer  
Employer (name & address) 
Phone:
Dates Employed:
 From  To
Summarize the nature of the work performed and job responsibilities.
Job Title
Starting hourly rate/salary
Final rate
Immediate Supervisor & Title
Phone
May we contact supervisor for reference?
 Yes No
Reason for leaving?
Past Employer #2  
Employer (name & address) 
Phone:
Dates Employed:
 From  To
Summarize the nature of the work performed and job responsibilities.
Job Title
Starting hourly rate/salary
Final rate
Immediate Supervisor & Title
Phone
May we contact supervisor for reference?
 Yes No
Reason for leaving?
Past Employer #3  
Employer (name & address) 
Phone:
Dates Employed:
 From  To
Summarize the nature of the work performed and job responsibilities.
Job Title
Starting hourly rate/salary
Final rate
Immediate Supervisor & Title
Phone
May we contact supervisor for reference?
 Yes No
Reason for leaving?

Comments (including explanation of any gaps in employment)

Skills & Qualifications: Summarize customer service skills & qualifications acquired from employment or other experience, which may qualify you to work with our company.

Please read:

I hereby certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize the references listed above, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons for any and all liability for any damages that may result from furnishing such information. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or if I am hired, my dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of Mellow Mushroom as amended by the company from time to time in its discretion.

Mellow Mushroom is a equal opportunity employer and does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment or a basis prohibited by local, state or federal law.

Full Name of Applicant: *  Date: *

  *Required Fields