WINDHAM JUNCTION COUNTRY STORE AND KITCHEN
128 NORTH LOWELL ROAD
WINDHAM, NEW HAMPSHIRE 03087
(603)434-7467
APPLICATION FOR EMPLOYMENT
It is our policy to provide equal employment opportunity to all qualified persons without regard to race, creed, color,
religious belief, sex, age, national origin, ancestry, physical or mental handicap, or veteran status.
Date __________________
Name: Last _______________________ First __________________ Middle __________
Street Address ___________________________________________________________
City ______________________________ State ____________ Zip _________________
Telephone ( ) ____________________ Additional Phone/ Cell___________________
Position applied for _______________________________________________________
How did you hear of this opening ____________________________________________
When can you start _____________________ Desired Wage $ ______________
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? [ ] Yes [ ] No
Are you looking for full time employment? [ ] Yes [ ] No
If no, what hours are you available? __________________________________________
Have you ever been convicted of a felony? [ ] Yes [ ] No
If yes, please fully describe the circumstances:
________________________________________________________________________
________________________________________________________________________
Education: School Name and Location Year Major Degree
High School _________________________________________________
College _____________________________________________________
College _____________________________________________________
Other _______________________________________________________
_____________________________________________________
In addition to your work history, are there are other skills, qualifications, or experience we should consider:
_______________________________________________________________________
_______________________________________________________________________
Employment History: (Start with most recent employer.)
Company name _______________________
Address __________________________________ Telephone _________________
Date Started _______ Starting Wage _______ Starting Position ___________
Date Ended ________ Ending Wage _______ Ending Position ___________
Name of Supervisor ________________ May we contact? [ ] Yes [ ] No
Responsibilities __________________________________________________________
Reason for leaving ________________________________________________________
Company name ______________________________________________________
Address __________________________________ Telephone _________________
Date Started _______ Starting Wage _______ Starting Position ___________
Date Ended ________ Ending Wage _______ Ending Position ___________
Name of Supervisor ________________ May we contact? [ ] Yes [ ] No
Responsibilities ________________________________________________________
Reason for leaving ______________________________________________________
Please bring application in personally and we will call if needed.
Attach additional information if necessary.
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge.
I understand that if I am employed, false statements on this application shall be considered sufficient cause for
dismissal. This company is hereby authorized to make any investigations of my prior educational and employment
history. I understand that employment at this company is "at will," which means that either I or this company can
terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by
statute. All employment will continue on that basis. I understand that no supervisor, manager, or executive of this
company, other than the president has the authority to alter the foregoing.
Signature _________________________ Date ____________________