ApplicAtion for EmploymEnt
An EQUAl opportUnity EmployEr
Citrine's policy is to provide employment, training, compensation, promotion and other conditions of employment without regard to
race, color, religion, sexual orientation, national origin, sex, age, disability, veteran status, medical condition, marital status or any other
legally protected status. Applicants must reapply at least once every two months to remain under consideration for employment.
pErSonAl informAtion
NAME
TEL. NO. ( )
First
Middle Initial
Last
OTHER NAMES USED FOR EMPLOYMENT OR EDUCATION (if any)
ADDRESS
SOCIAL
SECURITY NO.
Street/Apt.#
City
State Zip County
FOR WHAT POSITION(S) ARE YOU APPLYING?
FULL-TIME PART-TIME EITHER
PREFERRED RESTAURANT LOCATION?
ARE YOU UNDER THE AGE OF 18? YES NO
IF UNDER 18, STATE YOUR AGE
ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? YES NO
HAVE YOU BEEN CONVICTED OF A CRIME WITHIN THE LAST SEVEN (7) YEARS (other than a minor traffic violation) ? YES* NO
*Do not answer YES if any of the following conditions apply:
If the conviction or plea resulted in a pre-trial or post-trial diversion program; or
If the record of the conviction has been judicially ordered sealed, expunged or statutorily eradicated; or
If the conviction is a misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has
been judicially dismissed pursuant to Penal Code Section 1203.4; or
If the conviction is under California Health & Safety Code sections 11357(b) or (c), 11360(b) (formerly section 11360(c)), 11364, 11365, or
11550, or their statutory predecessors which relate to marijuana convictions that occurred 2 or more years ago.
IF THE ANSWER TO THE QUESTION ABOVE IS YES, EXPLAIN THE CIRCUMSTANCES BELOW WITHOUT IDENTIFYING THE NAMES OF
ANY OTHER PERSONS INVOLVED IN THE INCIDENT. (A "Yes" answer will not necessarily disqualify you from employment.)
DATE AVAILABLE FOR WORK
TOTAL HOURS AVAILABLE PER WEEK
(You may list time needed for religious practices/observances as "available" time.)
SUN
MON
TUES
WED
THURS
FRI
SAT
EARlIEST TIME
lATEST TIME
EDUcAtion
NAME & ADDRESS OF SCHOOlS ATTENDED
FROM
mo/yr
TO
mo/yr
CIRClE HIGHEST
GRADE/lEVEl COMPlETED
DEGREE/MAJOR
HIGH SCHOOl
9
10 11 12
COllEGE
1
2
3
4
GRADUATE
1
2
3
4
OTHER
1
2
3
4
a)
b)
c)
d)
ApplicAtion for EmploymEnt
rEcorD of U.S.A. militAry AnD rESErVE StAtUS
Service Dates
FROM mo
yr TO mo
yr Branch Reserve Unit Meeting Dates
Summarize skills, training or qualifications:
profESSionAl/pErSonAl rEfErEncES
NAME
ADDRESS
PHONE NUMbER
OCCUPATION
EmploymEnt HiStory
List each job held during the last seven (7) years with a minimum of three (3) employers. Start with your present or last job. Also,
include any periods of unemployment, military service, and volunteer and/or part-time work experience. If necessary, use an
additional sheet to include related work history beyond seven (7) years.
EMPlOyMENT
DATES (mo/yr)
COMPANy AND
MAIlING ADDRESS
SUPERVISOR'S
NAME/PHONE
SAlARy
yOUR JOb TITlESPECIFIC JOb DUTIES
REASON FOR
lEAVING
FROM
START
TO
FINAl
FROM
START
TO
FINAl
FROM
START
TO
FINAl
FROM
START
TO
FINAl
FROM
START
TO
FINAl
Have you ever been fired from a job or given the opportunity to resign rather than be fired? YES
NO
If yes, explain:
rEAD tHE folloWinG cArEfUlly, tHEn SiGn AnD DAtE tHE ApplicAtion
Please initial each of the following paragraphs:
Certification: I certify that the information I provided on this application is true and correct to the best of my knowledge, and I
agree to have this information checked by Citrine ("the Company"). I authorize the references listed to provide the Company with
information about my previous employment and any other information they may have. I release all parties and persons, including
the Company, from any and all liability for any damages for providing this information, consistent with state and federal law.
At will employment: I understand that nothing in this application is intended to be, or is, an offer of employment or a
promise of continued employment. I understand that if I become employed by the Company, my employment is for no
specific term. I further understand that, except for any periods of time that I am employed in a position covered by an express
written agreement that provides otherwise, my employment with the Company may be terminated at any time, with or
without cause and/or notice, at the will of either me or the Company. I further understand that no Company representative
has any authority to enter into any agreement with me different or contrary to the foregoing.
Eligibility verification: I understand that any false statement or omission on this application may prevent me from receiving
an offer of employment, 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 false statement or omission is discovered.
I understand that all offers of employment are conditioned on satisfactory proof of my identity, that I am of legal age and that
I have legal authorization to work in the United States, as well as the Company's receipt of satisfactory responses to reference
requests, my passing any required drug screening test, completion of a post-offer medical examination, if applicable, and
satisfactory completion of a background check, if applicable.
Applicant Signature
Date
Interviewer Signature
Date
ApplicAtion for EmploymEnt
to bE complEtED by ApplicAnt - ApplicAtion informAtion
NAME
First
Middle Initial
Last
to bE complEtED by HirinG pErSonnEl only
rAcE/EtHnic GroUp
SElEct only onE
American Indian/Alaska Native
Asian
Native Hawaiian/
Other Pacific Islander
Black/African American
Hispanic/Latino
White
Two or More Races
Decline Disclosure
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GEnDEr
Male
Female
Decline Disclosure
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SoUrcE coDE
Walk-in
Newspaper Advertisement
Employee Referral
Employment Agency
Female/Minority Group Referral
Community/Vocational Rehab Org
High School/College Referral
Job Fair/Recruiting Event
Internal Postings
Job Postings
Other (Explain)___________________
__________________________________
Internal Employee Application
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Job GroUp coDES
1A District Operating Partner
1B Operating Partner
1C Assistant Operating
Partner
4B Flavor/Service Experience
Specialist
Other
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intErViEW DAtE
Month
Day
Year
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2007
2008
2009
2010
2011
2012
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0
1
2
3
0
1
2
3
4
5
6
7
8
9
ApplicAtion DAtE
Month
Day
Year
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2007
2008
2009
2010
2011
2012
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0
1
2
3
0
1
2
3
4
5
6
7
8
9
DiSpoSition coDES
A = No position available within the last
60 days
B = More qualified applicants available
C = Unavailable to work required hours
D = Available type of work was not
acceptable
E = Unable to contact/unavailable for
interview
F = Wage not acceptable
G = Did not meet post-offer policy
requirements
H = Declined job offer
I = Did not show up for interview
J = Ineligible for rehire
K = Did not pass pre-employment test
L = Hired
M = Other
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NOTICE AND CONSENT CONCERNING CONSUMER REPORTS
AND INVESTIGATIVE CONSUMER REPORTS
This form, which you should read carefully before signing, has been provided to you because Citrine ("the Company") may request
consumer reports or investigative consumer reports in connection with your application for employment or, if you are or become
employed by the Company, during the course of your employment with the Company. Such reports may be requested for purposes
of evaluating your suitability for employment, promotion, reassignment, retention or other employment-related purposes.
Additionally, in the event of any claims or disputes between you and the Company, the Company may request consumer reports or
investigative consumer reports for purposes of evaluation and response, whether or not you remain in the employ of the Company
at the time such claims or disputes arise or are pursued.
The types of reports that may be requested from consumer reporting agencies under this Notice and Consent include, but are
not limited to: credit reports, criminal records checks, court records checks, driving records, and/or summaries of educational,
employment records and histories, and investigative consumer reports (reports in which the consumer reporting agency obtains
information regarding your character, general reputation, personal characteristics or mode of living). The information contained in
these reports may be obtained by consumer reporting agencies from public record sources or through personal interviews with your
co-workers, neighbors, friends, associates, current or former employers, or other people you know.
If the Company seeks an investigative consumer report for reasons other than suspicion of wrongdoing or misconduct by you, you
will receive a second notice indicating that such a report has been requested before the report is procured or caused to be made.
These additional notices, if issued, will advise you as to your further rights pertaining to investigative consumer reports.
If any adverse decision with regard to your application for employment with the Company or, if you are hired, during the course of
your employment, is made based in whole or part on the information contained in a consumer report, you will be notified as to the
basis for the decision and given a copy of the report, as well as a summary of your applicable rights.
CONSENT STATEMENT
I have carefully read and understand this Notice and Consent form and, by my signature below, I consent to the release of consumer
reports and/or investigative consumer reports, as described above, to the Company: (1) in conjunction with my application for
employment; (2) during the entire course of my employment, if any; and (3) after any such employment ends. I further understand
that any and all information contained in my job application or otherwise disclosed to the Company by me before, during or after
my employment, if any, may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports
requested by the Company and I confirm that all such information provided in connection with my job application is true and
correct. I understand that nothing in this Notice and Consent is intended to be, or is, an offer of employment or a promise of
continued employment. I understand that if I become employed by the Company, my employment is for no specific term. I further
understand that, except for any periods of time that I am employed in a position covered by a collective bargaining agreement or
express written agreement which provides otherwise, my employment with the Company may be terminated at any time, with or
without cause and/or notice, at the will of either myself or the Company.
NOTICE TO CAlIFORNIA APPlICANTS OR EMPlOyEES
In the event that the Company without the use of an investigative consumer reporting agency, obtains records documenting an
arrest, indictment, conviction, civil, judicial action, tax lien or outstanding judgment ("Public Records"), the Company shall provide
a copy of the Public Records to you within 7 days after receipt of the information, regardless of whether the record is in oral or
written form. You may waive your right to receive a copy of the Public Records by checking the box below.
Yes, I waive my right to receive a copy of Public Records obtained by the Company.
In the event that the Company obtains Public Records for purposes of conducting an investigation for suspicion of wrongdoing or
misconduct by you, the Company may withhold the information until the completion of the investigation.
Name of Applicant (Print)
Date
Applicant or Employee Signature
Social Security Number
Street Address
Date of Birth
City, State and Zip Code
Last
Name
First
Name
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