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Café Location: 617 4th Street, Eureka, ca 95501  707. 445. 4480


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Lost Coast Brewery & Café

Brewery Location: 123 West 3rd Street, Eureka, CA 95501  707.445.4484


Café Location: 617 4th Street, Eureka, CA 95501  707.445.4480




Employment Application for At-Will Employment

Applicant Information


Last Name




First




M.I.

Date




Street Address




Apartment/Unit #




City




State




ZIP




Phone




E-mail Address




Date Available




Social Security No.




Desired Salary




Position Applied for




Are you a citizen of the United States?

YES 

NO 

If no, are you authorized to work in the U.S.?

YES 

NO 

Have you ever worked for this company?

YES 

NO 

If so, when?




Are you 21 years of age or older? YES  NO 

Instructions for answering the following question regarding your criminal record history:

Do not respond “yes” concerning the following: arrests or detentions that did not result in conviction; referrals to, and participation in, any pretrial or post-trial diversion program; marijuana-related convictions more than two years old; convictions for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; convictions that occurred more than ten (10) years ago; misdemeanor convictions for which probations has been successfully completed or otherwise discharged and the case has been judicially dismissed; and first convictions for misdemeanors of drunkenness, simple assault, speeding, minor traffic violations, or disturbances of the peace or misdemeanor convictions where five (5) or more years have elapsed between the application date and the date of conviction or completion of incarceration, whichever is later.


(A conviction record will not necessarily be a bar to employment. Factors such as age at the time of the offense, type of offense and relevance to the job for which you are applying, seriousness and nature of the offense, and rehabilitation will be taken into account.)

Have you ever been convicted of a crime? YES  NO 

If YES, what was (were) the offense(s)?:

Date(s) and place(s) of conviction:

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



Military Service


Branch

From




To




Rank at Discharge




Type of Discharge




If other than honorable, explain









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 



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.

Signature




Date





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