Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Other

Race *

White

Black or African-American

American Indian / Alaska Native

Asian

Native Hawaiian / Other Pacific Islander

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you responsible for the care of any children/family members? *

Yes

No

Are you a US citizen? *

Yes

No

If you are a male, have you registered for Selective Service? *

Yes

No

N/A

Are you currently a recipient of SNAP or public assistance? *

Yes

No

Are you a veteran? *

Yes

No

Do you have any food service experience? *

Yes

No

Highest education level completed: *

Elementary/Middle School

Some High School

High School Diploma/GED

Technical School Certification

Bachelor's Degree

Master's Degree/Ph.D.

Do you have a stable place to live for the next six months? *

Yes

No

Current living situation: *

Living with Family or Friends

Renting

Own Home

Program/Shelter

Transitional Housing

Permanent Subsidized Housing

Other

Do you have any pending court cases? *

Yes

No

Do you have any current warrants? *

Yes

No

Have you ever been charged with any crimes of a sexual nature, regardless of the outcome?

Yes

No

Are you currently on any of the following: *

Parole

Probation

Work Release

Home Confinement

None

Have you ever used any of the following: *

Alcohol

Illegal Drugs

Neither

If you are sober, what is your clean date?

MM

DD

YYYY

Do you currently take medication for any of the above? *

Yes

No

Have you ever been diagnosed with a mental illness? *

Yes

No

Does any of your medication make you drowsy or affect your ability to work? *

Yes

No

Are you able to read, speak and comprehend English in a fast-paced environment? *

Yes

No

Are you able to hear in a noisy environment with background noise from a distance of 20 feet with reasonable accommodations? *

Yes

No

Are you able to stand for a minimum of 8 hours with two 15-minute breaks and lift 50 pounds with reasonable accommodations? *

Yes

No

I hereby certify that all statements made in this application and any attachments to it are true. I understand that any misstatement, misrepresentation or omission of fact may cause my application not to be considered; or, if I am employed, may cause my immediate dismissal. I authorize the REfire program to verify information contained in this application and attachments. I further authorize anyone having such information to release it. I understand that if I am selected for this position and I am 18 years or older prior to employment, a criminal history screening of my background may be conducted. I also authorize the release of the information in this application to REfire partners including CareerSource Capital Region, Big Bend Homeless Coalition and employer partners. *

I agree.

I do not agree.

Today's Date *

MM

DD

YYYY