132 North East Street, Indianapolis, IN 46204
P.317.423.3300, F.317.423.3372
 
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MAXINE'S CHICKEN & WAFFLES
Employment Application

APPLICANT INFORMATION
Last Name:      First:      M.I.      Date: 
Street Address:      Apt/Unit#:     
City:      State:      Zip:     
Phone:      E-mail Address:     
Date Available:      Desired Salary:     
Position Applied for:     
Are you a citizen of the United States? YES    NO    Are you authorized to work in the U.S.? YES    NO   
Have you ever worked for this company? YES    NO    If yes, when?     
Have you ever been convicted of a felony? YES    NO    If yes, explain.     

EDUCATION
High School:      Address:     
From:      To:      Did you graduate? YES    NO    Degree:     

College:      Address:     
From:      To:      Did you graduate? YES    NO    Degree:     

Other:      Address:     
From:      To:      Did you graduate? YES    NO    Degree:     

REFERENCES
Please list three professional references.
Full Name:      Relationship:     
Company:      Phone:     
Address:     

Full Name:      Relationship:     
Company:      Phone:     
Address:     

Full Name:      Relationship:     
Company:      Phone:     
Address:     

PREVIOUS EMPLOYMENT
Company:      Phone:     
Address:      Supervisor:     
Job Title:      Starting Salary:      Ending Salary:     
Responsibilities:     
From:      To:      Reason for Leaving:     
May we contact your previous supervisor for a reference? YES    NO   

Company:      Phone:     
Address:      Supervisor:     
Job Title:      Starting Salary:      Ending Salary:     
Responsibilities:     
From:      To:      Reason for Leaving:     
May we contact your previous supervisor for a reference? YES    NO   

Company:      Phone:     
Address:      Supervisor:     
Job Title:      Starting Salary:      Ending Salary:     
Responsibilities:     
From:      To:      Reason for Leaving:     
May we contact your previous supervisor for a reference? YES    NO   

MILITARY SERVICE
Branch:      From:      To:     
Rank at Discharge:      Type of Discharge:     
If other than honorable, explain:     

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Initials:      Date:     

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