Storm Restaurants- Hearthstone Application- English Question Title * 1. Legal Name OK Question Title * 2. Application Date Date / Time Date OK Question Title * 3. Local Mailing Address Street /Po Box CIty State Zip Code OK Question Title * 4. Physical Address Street City State Zip Code OK Question Title * 5. Do you currently live in Summit County, or the surrounding area? If the answer is no, when will you be in the area, and have you already secured housing? OK Question Title * 6. Phone Number OK Question Title * 7. Email Address OK Question Title * 8. What position(s) are you applying for? Server Host Busser/Food Runner Bartender Prep Cook Line Cook Dishwasher OK Question Title * 9. How did you hear about this position? OK Question Title * 10. Have you ever worked for any division of Storm Restaurants, Inc. (Hearthstone or Hearthstone Catering) before? Yes No OK Question Title * 11. If yes, Where and When? OK Question Title * 12. Are you now or have you ever applied for a position with any other division of Storm Restaurants, Inc. (Hearthstone or Hearthstone Catering)? Yes No OK Question Title * 13. If yes, Where and When? OK Question Title * 14. Are you 18 years of age or older? Yes No OK Question Title * 15. Do you have legal identification to work in the United States? Yes No OK Question Title * 16. Employment Record (most recent job) Employer and Address Job Title Dates of Employment (month/year) Duties & Responsibilities Supervisor Name & Phone Number Reason for Leaving OK Question Title * 17. continued Employer and Address Job Title Dates of Employment (month/year) Duties & responsibilities Supervisor Name & Phone Number Reason for Leaving OK Question Title * 18. continued Employer & Address Job Title Dates of Employment (month/year) Duties & Responsibilities Supervisor Name & Phone Number Reason for Leaving OK Question Title * 19. Educational Data High School: Name/Location / Degree / Graduated (Y/N) / Subject Studied College: Name/Location / Degree / Graduated (Y/N) / Subject Studied Other: Name/Location / Degree / Graduated (Y/N) / Subject Studied OK Question Title * 20. Skills- Do you speak any foreign languages? Is the answer is yes, please specify. Yes No Other (please specify) OK Question Title * 21. Skills- Do you read any foreign languages? Is the answer is yes, please specify. Yes No Other (please specify) OK Question Title * 22. Skills- Do you write any foreign languages? Is the answer is yes, please specify. Yes No Other (please specify) OK Question Title * 23. References Name Company / Title Address Phone Number OK Question Title * 24. continued Name Company / Title Address Phone Number OK Question Title * 25. continued Name Company / Title Address Phone Number OK Question Title * 26. Are you able to lift/push/pull items weighing up to 50 lbs. if the position you are applying for requires it? Yes No OK Question Title * 27. I certify that all information contained in this application is true and complete to the best of my knowledge. I understand that any mistakes or incorrect statements render this application void, and if employed, could be cause for termination. I hereby authorize investigations and inquiries of my driving record, employment history, educational background, or criminal conviction history, as may be necessary in arriving at an employment decision. I hereby authorize past employers, schools, and references to give information in responding to inquiries in connection with this application. I release said companies, schools or persons from all liability for issuing this information. If employed, I agree to conform to the rules and regulations of the Company. I understand that my employment can be terminated, with or without notice at any time, at the option of the Company or myself. I hereby authorize the Company to deduct from my final paycheck upon termination any debts I may owe to the Company (including rent, or amounts due for lost or damaged items for which I may be accountable). In addition, I agree to fully comply with all policies concerning alcohol, drugs, safety, and loss control, and further consent to such searches, inspections, examinations, and tests as may be required. Signature Date OK DONE