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Job Application
Date
Position Applying For
Part Time   Full Time
Name
Phone Number
Email Address
Street Address
City
State
Zip Code
How long have you lived in this metropolitan area during your present stay?
Do you have a valid driver's licsense?
Yes   No
Which State
Are you 18 years old or older?
Yes   No
Are you legally able to work in the United States? (Proof will be required upon hire)
Yes   No
List and explain any special job skills and/or qualifications you have
When can you begin work?
When are you available to work?
Do you anticipate any change in your work availability in the near future?
How did you hear about the job?
Why should we hire you?
Have you ever applied with Counter Culture before?
Yes   No
If yes, please give dates and position(s)
Do you know anyone who has worked or presently works for this company?
Have you ever shopped at Counter Culture before?
Yes   No
How do you enjoying spending your sparetime? (You may omit any activities which indicate your race, religious creed, national origin, ancestry, gender, marital status or age.)
Have you ever been convicted of a crime?
Yes   No
Do you have a college degree?
Yes   No
If yes, please indicate the degree and area of specialization
Are you presently enrolled in school?
Yes   No
Do you have plans to continue your formal education in the future?
Yes   No
What are your occupational goals?
High School
Name
Location
Area of Study
Last Year Completed
College
Name
Location
Area of Study
Last Year Completed
Other
Name
Location
Last Year Completed
Work Experience
Begin with your present or most recent job
If this is your current employer, may we contact them?
Yes   No
Beginning Date
Ending Date
Number of months on the job
Full Time or Part Time
Name of business
Phone
City
State
Position Held
Supervisor
Job Duties
Reason for Leaving
Beginning Pay
End Pay
Beginning Date
Ending Date
Number of months on the job
Full Time or Part Time
Name of business
Phone
City
State
Position Held
Supervisor
Job Duties
Reason for Leaving
Beginning Pay
End Pay
Beginning Date
Ending Date
Number of months on the job
Full Time or Part Time
Name of business
Phone
City
State
Position Held
Supervisor
Job Duties
Reason for Leaving
Beginning Pay
End Pay

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