Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position Desired *

Barista

Donut Prep (4a-8a)

Back of House Cook (Part TIme)

Dishwasher (Friday, Saturday, Sunday)

Desired Employment *

5-10 hrs/week

10-20 hrs/week

20-25 hrs/week

25-30 hrs/week

Full Time Only

Available Start Date: *

MM

DD

YYYY

Education *

Highest Education Completed:

High School

College

Phone #

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Phone 2

(###)

###

####

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Phone

(###)

###

####

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Please read carefully and sign below. *

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 correct to the best of my knowledge. I further certify that I, 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 the time elapsed before discovery. Nova Coffee Co is a business that works in compliance with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests. I understand that my below signature indicates my ability to complete all necessary functions of the position I am applying for. If I cannot preform all the necessary functions, I understand must indicate this before I am offerered a position of employment at Nova Coffee Co. Furthermore, I understand that Nova Coffee Co may refuse to hire relatives or otherwise related persons of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest. I hereby authorize Nova Coffee Co to thoroughly investigate my references, work record, education and other matters related to my suitability for employment unless otherwise specified above. I further, authorize the references I have listed to disclose to Nova Coffee Co any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Nova Coffee Co, 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 related to such investigation or disclosure. 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 me and Nova Coffee Co. 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 without prior notice, at the option of either myself or Nova Coffee Co, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and Nova Coffee Co's designated representative. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. “Public records” are defined by Ohio state law and means records documenting an “arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment.” (3313.533 of the Revised Code) Any public records request conducted by internal personnel employed by Nova Coffee Co will only be used to the extent allowed by federal, state, or local law.

First Name

Last Name

Date signed

MM

DD

YYYY