Ball & Chain - Employment Application WE ARE PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER First Name*Last Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Date of Birth* Social Security Number (last 4 digits)*Emergency Contact*Emergency Contact Phone*Relationship*Marital Status*SingleMarriedDivorcedWork Authorization*Select OneAuthorized to work in the USRequire SponsorshipOtherPlease ExplainName of any relatives currently employed by the companyReferred byEmployment Type*OpenFull TimePart TimeTemporaryPosition Desired*AnyBarbackBartenderCleanerCookDancerDishwasherFood Runner / BusserHost / HostessManagerServerRate of pay desired*Please attach your resumeWORK INFORMATIONHave you ever worked for this company before? Check box for "YES" Are you currently employed? Check box for "YES" How long have you been unemployed?Physical HistoryList any physical limitationsHave you ever been injured on the job?*YesNoPlease list the nature of the injury(s)*How much time have you lost from work in the past year from illness?Have you ever received worker's compensation?*YesNoWorkers comp start date:* Workers comp end date:* MILITARY STATUSHave you ever been in the U.S. Armed Forces?*YesNoMilitary Branch*Select OneArmyNavyAir ForceMarinesCoast GuardRank at time of discharge*Date of Discharge* EducationEducation Level*Select OneNoneCurrent High School or GED StudentHigh School Diploma or GEDTrade or Technical School DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreePhDOtherLast School Attended*Have you ever been convicted of a felony?*YesNoDate of conviction* Please explain*WORK HISTORYPlease provide your most recent work history firstFormer Employer*Former Employer Phone*Position*Supervisor*Date Employed From* Date Employed To* Reason for leaving*Former Employer 2Former Employer 2 PhonePositionSupervisorDate Employed From Date Employed To Reason for leavingCertification* I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and true to the best of my knowledge. I further certify that the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed regardless of time elapsed before discovery. Background Check* I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving my prior notice to such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way to such investigation or disclosure. Arbitration* I hereby agree to submit binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution, which might arise out of my employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Association of Arbitration. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution either oral or written. At Will Employment* I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment if hired, is intended to create an employment contract between the company and me. In addition I understand and agree that if I am employed my employment is for no definite or determinable period and may be terminated at any time with or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative. Misrepresentation* I agree and understand that any misrepresentation of information given above shall be considered an act of falsification. I agree and understand that the employment is factual. I agree and understand that if hired, I will be on a probationary period during which time I may be discharged without recourse. Signature*Please type your name to the left as this represents your digital signature. By signing this you are stating that all information submitted on this form is true and accurate.