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Cirque Lodge Inc. – Application for Employment

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Name*
First Middle Last
Phone*
Email*
Application Date*
Date Format: MM slash DD slash YYYY

Position & Availability
Position Applied For*
Position Type:*
Regular / Volunteer*
Starting Salary Expectation*
Date of Availibility*
Date Format: MM slash DD slash YYYY
ARE YOU 18+ YEARS OLD?*
- Yes
- No
ARE YOU AVALIABLE TO WORK ALL HOURS AND DAYS?*
- Yes
- No
DO YOU HAVE A VALID DRIVERS LICENSE?*
- Yes
- No
ARE YOU ABLE TO PASS A DRUG SCREEN?*
- Yes
- No
ARE YOU ABLE TO PROVIDE DOCUMENTS SHOWING YOU ARE AUTHORIZED TO WORK IN THE U.S.?*
- Yes
- No
ARE YOU PHYSCIALLY ABLE TO PERFORM THE DUTIES FOR THE POSTION WHICH YOU ARE APPLYING?*
- Yes
- No
- NOT SURE
ARE YOU ABLE TO PASS A CRIMINAL BACKGROUND SCREENING?*
- Yes
- No
(Criminal convictions shall not automatically disqualify applicants from employment)
IF NO TO ANY OF THE ABOVE, PLEASE EXPLAIN IN DETAIL, NOTING RESTRICTIONS, HISTORY & ALL CRIMINAL CONVICTIONS:
HAVE YOU EVER APPLIED FOR A POSTION WITH CIRQUE LODGE, INC. IN THE PAST?*
- Yes
- No
IF YES, WHEN DID YOU APPLY?
Date Format: MM slash DD slash YYYY
WERE YOU HIRED?
- YES
- NO

EDUCATION/TRAINING
HIGH SCHOOL

Name*
Address*
YEAR GRADUATED*
Date Format: MM slash DD slash YYYY
College

Name
Address
Grade Completed
Major
Degree Received
College

Name
Address
Grade Completed
Major
Degree Rec'd
Grad School

Name
Address
Grade Completed
Major
Degree Rec'd
Trade School

Name
Address
Major
Degree Rec'd
ADDITIONAL CERTIFICATIONS AND/OR TRAINING OF NOTE:

EMPLOYMENT HISTORY
NAME OF COMPANY*
CITY & STATE*
City State
PHONE NUMBER*
JOB TITLE*
ENDING PAY*
REASON FOR LEAVING*
EMPLOYMENT TIME*
From (Mo. / Yr.) To (Mo. / Yr.) Total (Yrs / Mos.)
MAY WE CONTACT THIS EMPLOYER?*
- Yes
- No
NAME OF COMPANY*
CITY & STATE*
City State
PHONE NUMBER*
JOB TITLE*
ENDING PAY*
REASON FOR LEAVING*
EMPLOYMENT TIME*
From (Mo. / Yr.) To (Mo. / Yr.) Total (Yrs / Mos.)
MAY WE CONTACT THIS EMPLOYER?*
- Yes
- No
NAME OF COMPANY
CITY & STATE
City State
PHONE NUMBER
JOB TITLE
ENDING PAY
REASON FOR LEAVING
EMPLOYMENT TIME
From (Mo. / Yr.) To (Mo. / Yr.) Total (Yrs / Mos.)
MAY WE CONTACT THIS EMPLOYER?
- Yes
- No

REFERENCE VERIFICATION
Please list 3 references that may be contacted on your behalf:
NAME OF REFERENCE*
JOB TITLE*
COMPANY*
PHONE*
NAME OF REFERENCE*
JOB TITLE*
COMPANY*
PHONE*
NAME OF REFERENCE*
JOB TITLE*
COMPANY*
PHONE*

Employee Medication Information

Cirque Lodge does not hire anyone taking the following medications. All staff must remain free from these medications during their employ:

Suboxone, Subutex, Buprenorphine, Methadone, Lorazepam (Ativan), Diazepam (Valium), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Nordazepam, Medazepam (Ansilan), Alprazolam (Xanax), Zolpidem (Ambien), Temazepam, Oxazepam (Serax), Flurazepam

Cirque Lodge must be notified if you are ever prescribed the following medications. You will be required to bring in a copy of your prescription and may not be able to work while taking it. You may be asked to speak with our Medical Director regarding the prescription:

Lortab, Percocet, Oxycodone, Hydrocodone Oxycontin, Fentanyl, Codeine, Darvocet, Demerol, Endocet, Roxicodone, Dilaudid, Hydromorphine, Morphine, Soma, Phenobarbital, Barbitutates, Norco

Cirque Lodge must be notified if you are ever prescribed the following medications. You will need to speak with our Medical Director regarding the prescription prior to you starting the medication and/or prior to starting employment:

Amphetamines, Adderall, Concerta, Vyvanse, Ritilan, Provigil, Nuvigil, Phentermine

I hereby certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any statements checked by the Company unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the Company contacts, to provide the Company any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Company as well as from the use or disclosure of such information by the Company or any of it’s agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive or offer or, if I am hire, my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the Company, as amended by the company from time to time in its discretion. In the event that the applicant agrees to accept a position with the company, the applicant and the company agree that employment relationship between the company and the employee is an at will relationship and that the employment relationship and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of either the company or the employee. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an legal authority to work in the United States.
CIRQUE LODGE, INC. IS AN EQUAL OPPORTUNITY WITHOUT REGARD TO RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, AGE, MENTAL OR PHYSICAL HANDICAP, MARITAL OR VETERAN’S STATUS.
Date
Date Format: MM slash DD slash YYYY
Print Name
Signature Required at Interview

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HIGH SCHOOL
Name*	Address*	YEAR GRADUATED* Date Format: MM slash DD slash YYYY

College
Name	Address	Grade Completed	Major	Degree Received

College
Name	Address	Grade Completed	Major	Degree Rec'd

Grad School
Name	Address	Grade Completed	Major	Degree Rec'd

Trade School
Name	Address	Major	Degree Rec'd

Step 1 of 7

Position & Availability

EDUCATION/TRAINING

EMPLOYMENT HISTORY

REFERENCE VERIFICATION