DiBellas is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans. If you fall into one of these protected classifications, we invite you to identify to yourself and receive coverage under our company’s Affirmative Action Plan. You may inform us of your desire to benefit under the program at this time and/or any time in the future.

Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts.

Choose one race/ethnic group. Submission of information is voluntary.

Gender:	Male Female
Race/Ethnic Group:	Hispanic or Latino White Black or African American
	Native Hawaiian or Other Pacific Islander Asian
	American Indian or Alaska Native Two or more races

Definitions

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.

DiBellas (the Company) is an equal opportunity employer, which makes employment decisions without regard to race, color, gender, religion, national origin, age, disability, marital status, veteran status, sexual orientation or any other characteristic protected under federal, state or local law. The Company also reasonably accommodates individuals with disabilities and bona fide religious beliefs. It complies with, and fully supports the Americans with Disabilities Act.

The information requested on this form and its supplement is needed to evaluate your application for employment with this Company. All questions on the form must be answered. Incomplete applications will not be processed.

APPLICANT’S PERSONAL DATA

Name (Last, First, Middle)	Today's Date mm/dd/yyyy
Address (Street, PO Box) City	Have you previously been employed by DiBellas? YesNo When? Position?
StateZip Email Address	Have you previously submitted an employment application? YesNo When? Position?
If you are under 18 years of age, please state your date of birth (no one under age 16 may be hired)

APPLICANT’S EMPLOYMENT DATA

Position applying for:	Date available for work: mm/dd/yyyy
Type of position desired (select one) Full Time Part Time Temporary Co-op/Intern If hired, will you be able to work the scheduled days and hours required, which may include daily and weekly overtime? YesNo	Minimum salary requirement: $ How were you referred to DiBellas? May we contact you at work?Yes No Business Telephone
Which DiBellas location are you applying to work at?

DAY / HOURS AVAILABLE

Day	Mon	Tues	Wed	Thur	Fri	Sat	Sun
From
To

RESIDENTIAL HISTORY

Date	Address	City	State	Zip

GENERAL INFORMATION

Are you a U.S. Citizen? Yes No
If no, do you have a legal right and necessary documents to work in the U.S.? Yes no
Did you ever work for any employers under a different name? YesNo If yes, which name? If yes, which employer?	Have you been convicted of a felony involving a crime of violence, theft or breach of trust? YesNo If yes, please explain:
Have you ever been discharged by any company? Yes No Why?	Have you ever been counseled or disciplined for being late or absent from work or school?
Do you have reliable transportation?

WORK HISTORY

Start with your most recent position. If you have worked for any company as a temporary/contract employee, please specify that clearly under the appropriate employer, making sure to include the agency’s name and telephone number. Give accurate summaries of your duties, concentrating on major aspects of the position including number of personnel supervised, financial responsibilities and major accomplishments. Periods of unemployment should also be noted. Leave no gaps in time sequence. If additional space is required to cover the last 5 years, please use a separate sheet. Please do not substitute a resume in lieu of this information. An incomplete application will not be processed.
From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, when? mm/dd/yyyy

EDUCATION

	Name of School (No Abbreviations)	Location City/State	Dates of Attendance	Highest Grade Completed	Diploma/Degree Acquired
High School
College

Vocational/Technical
Other

U.S. MILITARY SERVICES HISTORY

Branch of Services	Technical Specialization	Rank Attained

REFERENCES

Please provide the names and contact information for three personal and professional references:

Name:
Relationship:
Contact Information:
Telephone:

Have you ever eaten at DiBellas before? If yes, please indicate the location and tell us about your experience.

Why do you want to work here?

What is your proudest work accomplishment?

Great customer service is extremely important here at DiBellas. What does great service mean to you?

Tell me about a time you had a bad customer experience. What happened?

What are your hobbies and interests?

What are your goals for the next 5 years?

APPLICANT AUTHORIZATION AND CONSENT
FOR RELEASE OF INFORMATION

    "I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time with or without notice, and the Company has the same right. No one other than the President of the Company has the authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing.
    This release and authorization acknowledges that the Company may now, or at any time while I am employed, conduct a verification of my education, previous employment/work history, credit history for certain positions, or motor vehicle records. The Company may also contact personal references, require that I be tested for the presence of drugs or alcohol, and receive any criminal history record information and/or other information as deemed necessary to fulfill the job requirements.
    Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act and/or other applicable laws. The results of this verification process will be used to determine employment eligibility under this Company’s employment policies. I authorize the Company and any of its agents/designated Company personnel, to disclose orally and in writing the results of the verification process. The information obtained will not be provided to any other parties other than to the designated authorized representatives of this Company. All results will be kept CONFIDENTIAL.
    I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as cause for possible dismissal.
    I have read and understand this consent for release of information, and authorize the background verification, and I do hereby authorize the Company to contact orally or in writing, any third parties to obtain information which the Company deems necessary and appropriate in conjunction with my application and qualifications for employment, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of information.
    I hereby authorize the Company to receive the results of any and all drug tests I have taken in any previous employment. This release specifically authorized the release of any confirmed, positive test results and a full and complete description of any disciplinary action, which followed.
    I so hereby agree to forever release and discharge the Company, and its affiliates and employees to the full extent permitted by law from any claims, complaint filed with any agency arising from the retrieving and reporting of information."

I agree to the terms above.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking records. It is confidential and will not be used for employment consideration and/or any other purpose.

Name

Maiden Name and/or Former Name

Social Security Number

Home Telephone Number

Driver's License Number

State

Name that your Driver’s License # is under

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