Position you are applying for:

Dining Room Kitchen Sales Person
Cook Host/Hostess Dishwasher
Busser Delivery

Name:
Email:
Address:
City:
Length of time at residence:
Phone:
Social Security number:
Are you over 18? Yes No
If no, state date of birth:
Are you legally able to work in the United States?: Yes No
Have you ever worked at Chix before? Yes No
If yes, please list the reason for leaving:

Previous Jobs:

1.   from to
2.   from to
3.   from to

Currently Employed ? Yes No
If yes, where?:

May we contact your current employer? Yes No
May we contact your past employers? Yes No

Type of employment desired:
Full Time Part Time Temporary Other

Total hours desired per week:

Do you have reliable transportation?: Yes No

Indicate what times you are available to work each day:

Do you have any special qualifications or training for this type of work?

If yes, please list:

Is there any reason you would not be able to perform the duties of this position? (Including, but not limited to lifting, carrying, bending, and standing for long periods of time.) Yes No

Highest level of education completed:
G.E.D. High School Associates Bachelors

I hereby state that the information on this application is complete and accurate to the best of my knowledge. If employed, I also understand that omissions or false statements could result in termination.

Name: Date: