Canyon

Pre-Employment Questionnaire, Feldman’s Wrong Way Diner is an Equal Opportunity Employer. Applicants are welcome and will be considered without regard to race, gender, age, national origin, color, religion, disability, military status, or any other basis protected by applicable federal, state or local law.

All areas must be completed in order for application to be considered!

Personal Information

Name (Last Name, First)

Phone Number

Email Address

Social Security No.

Present Address

City

State

Zip

Permanent Mailing Address

City

State

Zip

Education History

 

Name and Location of School

Years Attended

Did You Graduate?

High School

College

Trade, Business

Former Employers

(Start with most recent one first)

Name & Address of Employer

Contact Person

Phone Number

Position

Salary

Employed From - To (Date/Month/Year)
to

Reason For Leaving

Name & Address of Employer

Contact Person

Phone Number

Position

Salary

Employed From - To (Date/Month/Year)
to

Reason For Leaving

Name & Address of Employer

Contact Person

Phone Number

Position

Salary

Employed From - To (Date/Month/Year)
to

Reason For Leaving

Name & Address of Employer

Contact Person

Phone Number

Position

Salary

Employed From - To (Date/Month/Year)
to

Reason For Leaving

Work Availability

Availability: Please check the boxes for the days you're available to work

Part Time

Full Time

 

Wed.

Thurs.

Fri.

Sat.

Sun.

Mon.

Tues.

How many hours a week would you like to work?

AM

PM

Questionnaire

Position Desired

Date You Can Start

Are You Employed?

May We Contact Employer?

Are you authorized to with in the US?

If hired can you show proof of your legal right to work in the US?

Do you have reliable transportation?

 

Have you ever been convicted of a felony?

If you have been convicted, please explain.

Are you currently charged with a crime involving violence, sex, stalking, minors, theft, property damage, fraud, robbery or drugs?

Feldman’s Wrong Way Diner is a Drug Free Workplace. As a condition of employment you may be required to submit to a substance abuse test and a physical examination.

Are you willing to do so?

How did you hear about Feldman's TOO?

Agreement

By submitting this application you agree to the information below. If you have any questions about the agreement please let us know.

If I am hired at Feldman’s Wrong Way Diner, I agree that I will be an at-will employee, which means that either I or Feldman’s Wrong Way Diner may end my employment at any time, with or without cause or notice. I agree that no written materials or verbal statements by Feldman’s Wrong Way Diner will constitute an express or implied contract of continued employment and that this at-will relationship can only be modified in writing by Feldman’s Wrong Way Diner’s President. I agree that, if hired, I will obey Feldman’s Wrong Way Diner’s rules, including treating confidentially any information I learn during my employment.

I am not a current user of illegal drugs, and I agree I will never work under the influence of drugs or alcohol.

There is nothing in my background that would cause a risk to Feldman’s Wrong Way Diner’s customers, employees, or property. I authorize Feldman’s Wrong Way Diner to conduct reference checks, criminal and driving record checks, and other consumer report investigations. I release all parties from any liability from providing such information to Feldman’s Wrong Way Diner. In this regard, I understand that conviction of a crime will not necessarily disqualify me from consideration for employment. I understand that the nature and the date of the offense and the relevance of the offense to the position(s) applied for will determine my eligibility for employment.

I certify that the information I have provided to Feldman’s Wrong Way Diner is true and complete. I agree to notify Feldman’s Wrong Way Diner immediately if any of the information provided has changed. I agree that any false information or omissions allows Feldman’s Wrong Way Diner to refuse to hire me, or to terminate my employment at any time.

Authorization For Release of Information

I hereby authorize any investigator or duly accredited representative of (employer) bearing this release to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use by (employer) and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

Agreement To Arbitrate

Because of the delay and expense of the court systems, Feldman’s Wrong Way Diner and I agree to use confidential binding arbitration, instead of going to court, for any claims that arise between me and Feldman’s Wrong Way Diner, it’s related companies, and/or their current or former employee. Without limitation, such claims would include any concerning compensation, employment (including, but not limited to, any claims concerning sexual harassment or discrimination), or termination of employment. Before arbitration, I agree: (1) First to present any such claims in full written detail to Feldman’s Wrong Way Diner; (2) next, to complete any Feldman’s Wrong Way Diner internal review process; and (3) finally, to complete any external administrative remedy (such as with the Equal Employment Opportunity Commission). In any arbitration, the then prevailing employment dispute resolution rules of the American Arbitration Association will apply.

Applicant's Name

Date

Name of Parent or Guardin (if applicant is under 18)

Image verification

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Feldman's Wrong Way DinerFeldman's Wrong Way DinerFeldman's Wrong Way Diner
Hours Every day 11 am - 10 pm