Pickerman's Soup & Sandwiches® of La Crosse

OF LA CROSSE

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Employment

Online Application for Employment

First Name: Last Name:
Street Address: City:
State: Zip Code: Phone Number:
E-Mail Address (if applicable):
How long have you lived at this address?

Employment History
#1) Employer: City: State:
      Dates - From: , Year:
                     To: , Year:
     Duties: Reason for Leaving:
     Supervisor: Phone Number:

#2) Employer: City: State:
      Dates - From: , Year:
                     To: , Year:
     Duties: Reason for Leaving:
     Supervisor: Phone Number:

#3) Employer: City: State:
      Dates - From: , Year:
                     To: , Year:
     Duties: Reason for Leaving:
     Supervisor: Phone Number:

#4) Employer: City: State:
      Dates - From: , Year:
                     To: , Year:
     Duties: Reason for Leaving:
     Supervisor: Phone Number:

     Position Applying for:
     Are you eligible for employment in the United States:
     Are you 18 years or older? If not, state your date of birth:
     If under age 18, how many hours per week are you employed elsewhere?
     Daily Availability:

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

I verify that all the information I have provided on this online application is current and truthful. Electronic Signature: (full name) Date: