POSITION INTEREST AND PERSONAL INFORMATION Question Title * 1. Which location would you prefer working? Butler North St. Augustine West Tennessee Street Durbin Park Strand Any Question Title * 2. Position applied for: Cook Server Host/Hostess Buser Dishwasher Expeditor Question Title * 3. SERVERS AND HOST/HOSTESS ONLY:What Point of Sale System(s) are you proficient PosiTouch Aloha Micros Other None Question Title * 4. What rate of pay will your require for this position. Question Title * 5. Type of work interested in: Full time Part time Permanent Second Job Temporary Seasonal Question Title * 6. Check ALL OF THE DAYS that you ARE available to work from 7:00 a.m. to 4:00 p.m.*Applicants must be available EVERY SATURDAY, SUNDAY and HOLIDAY to be considered for employment. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Question Title * 7. Personal Information Name: * Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Email Address: Phone Number: * Question Title * 8. What date will you be available and/or how much notice do you require before beginning employment: Question Title * 9. Languages Spoken, Read and Written. English Spanish Other (please specify) Question Title * 10. Personal Information Continued Yes No Are you legally permitted to work in this country? Are you legally permitted to work in this country? Yes Are you legally permitted to work in this country? No Have you ever been convicted of a crime? Have you ever been convicted of a crime? Yes Have you ever been convicted of a crime? No Have you ever worked for Keke’s Breakfast Cafe? Have you ever worked for Keke’s Breakfast Cafe? Yes Have you ever worked for Keke’s Breakfast Cafe? No Do you require special accommodations to perform the job applied for? Do you require special accommodations to perform the job applied for? Yes Do you require special accommodations to perform the job applied for? No Use this space to explain any above. Next