Pocono Mountains PA Bed and Breakfast Lodge — Settlers Inn B&B in Pennsylvania

Instructions: Please answer all questions.
An applicant who provides unrequested information will be automatically rejected.

Date:

Personal Information

First Name

Last Name

Social Security #

E-Mail Address

Address

City

State

Zip Code

Phone #

Alternate Phone #

Referred by

Are you eligible to work in the United States?

No Yes

Are you over 16 years old?

No Yes

If you are under age 18, do you have an
employment/age certificates?

No Yes

Have you been convicted of or pleaded no
contest to a felony within the last five years?

No Yes

If yes, please explain:

Employment Information

Position for which you are applying

Are you employed at the present time?

No Yes

Position/Availability

Position Applied For

Days/Hours Available:

Monday	from	to
Tuesday	from	to
Wednesday	from	to
Thursday	from	to
Friday	from	to
Saturday	from	to
Sunday	from	to

What date are you available to start work?

Education

Name and Address Of School - Degree/Diploma - Graduation Date

Skills and Qualifications: Licenses, Skills, Training, Awards

Employment History

Present or Last Position

Employer

Supervisor

Address

Phone

Position Title

From To

Responsibilities

Salary

Reason for Leaving

Previous Position

Employer

Supervisor

Address

Phone

Position Title

From To

Responsibilities

Salary

Reason for Leaving

May We Contact Your Present Employer?

No Yes

References

1. Name/Title

Address

Phone

2. Name/Title

Address

Phone

3. Name/Title

Address

Phone

By submitting this application, I declare that the information provided by me is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on this application may preclude an offer of employment, or may result in a withdrawal of an employment offer, or may result in my discharge from employment if I am already employed at the time the misrepresentation or omission is discovered. I authorize the verification of any or all information listed above.

Name

Date