Employment

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position applying for

last name

first name

address

city

state

zip

day telephone

evening telephone

cell telephone

email address

If previously employed by Pure Adult Ultra Lounge, show dates of employment.
From: / To: /

Are you related to anyone presently employed at Pure Adult Ultra Lounge?
No Yes - If Yes, who?:

Have you ever been convicted of a felony?
No Yes - If Yes, please explain:

Education

High School Graduate or Equivalent?
No Yes

Last Attended: High School College Other:

Course of Study?

Dates Attended:

Name of School:

Location:

Degree (BS, BA, MA, etc):

Past work Experience

Company Name:
Address:
Telephone Number:	(	) -
Job Title:
Full Time Part Time Volunteer
Duties


Supervisor:
From: / To: /
Starting Wage:	$
Ending Wage:	$
Reason for leaving:

Citizenship / Availability / Military

Are you a US citizen?
No Yes
If No, Visa Class:

Are you available to work shift work if the position you are applying for requires it?
No Yes

Are you a veteran of the United States Military Service?
No Yes - Branch:

References

Give name, address and telephone number of three references who are not related to you and are not previous employers.

Name:
Address:
Phone Number:
Occupation:
Years Known:

Name:
Address:
Phone Number:
Occupation:
Years Known:

Name:
Address:
Phone Number:
Occupation:
Years Known:

Resume

If you have a resume to send, paste it into the box below:

Age Requirement

Date of Birth:	/ /
Sex:

PURE ADULT ULTRA LOUNGE IS AN EQUAL OPPORTUNITY EMPLOYER No person employed by Pure Adult Ultra Lounge or seeking employment with the Pure Adult Ultra Lounge shall be appointed, promoted, reduced, removed, or in any way favored or discriminated against because of political or religious opinion or affiliations, race, color, sex, national origin, or physical handicap. The submittal of this document via e-mail constitutes your acknowledgment that the information provided is true to the best of your knowledge. Any misrepresentations will be reason for dismissal.

I agree that any false statements in this application will be sufficient cause for rejection or dismissal. I hereby grant permission to investigate any of the statements in this application and to submit to a medical examination if required. The use of this application does not indicate positions are open and does not obligate Pure Adult Ultra Lounge in any way.

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