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La Coppa Employment Application

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Applicant Information  (* denotes required entry)
Position(s) applied for:*    
Location(s) applied for:*    
Type of Employment Desired:*    
Attach a Resumè (optional)
How were you refered to us?:    
First Name:*     Last Name:*     Initial: 
Phone:*     Cell Phone:     Email:* 
Address:*     City:*     State:*     Zip:* 
Date Available to Start:*   /   /     Salary Requirements: 
If you are under 18 years of age, can you provide a work permit?: 
If no, please explain: 
Are you legally allowed to work in the United States?:* 
Have you ever pleaded guilty, no contest or been convicted of a crime?:* 
If yes, give dates and details:
Answering yes to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and the nature of the violation, rehablilitation and position applied for will be considered.
Education History
Name and Location of High School: 
Status?: 
Name and Location of College: 
Status?: 
Degrees Completed: 
Trade, Business or Correspondence School: 
Subjects Studied: 
Years attended:  Did you graduate?: 
Summarize your Special Skills, Qualifications or Licensing
Previous Employment (begin with most recent position)
Previous Employment #1 Information (most recent)
Dates of Employment:    From   /   /        To   /   / 
Position(s) Held: 
Company Name: 
Address:     City:     State:     Zip: 
Phone:     Supervisor:     Title: 
Responsibilities:
Starting Salary and Title:     Ending Salary and Title: 
Reason for Leaving: 
May we contact this employer for a reference?:
Previous Employment #2 Information
Dates of Employment:    From   /   /        To   /   / 
Position(s) Held: 
Company Name: 
Address:     City:     State:     Zip: 
Phone:     Supervisor:     Title: 
Responsibilities:
Starting Salary and Title:     Ending Salary and Title: 
Reason for Leaving: 
May we contact this employer for a reference?:
Previous Employment #3 Information
Dates of Employment:    From   /   /        To   /   / 
Position(s) Held: 
Company Name: 
Address:     City:     State:     Zip: 
Phone:     Supervisor:     Title: 
Responsibilities:
Starting Salary and Title:     Ending Salary and Title: 
Reason for Leaving: 
May we contact this employer for a reference?:
Notes/Other Information
Notes/Information: 
Confirmation of Information
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained above and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited the the Americans with Disabilities Act (ADA) and other federal and state laws."
* The information above is accurate and complete.
Today's Date:  04/25/2014