Cirque Lodge Inc. – Application for Employment Step 1 of 7 14% Name* First Middle Last Phone*Email* Application Date* MM slash DD slash YYYY Position & AvailabilityPosition Applied For* Position Type:*Full TimePart TimeRegular / Volunteer*RegularVolunteerStarting Salary Expectation* Date of Availibility* 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? MM slash DD slash YYYY WERE YOU HIRED? YES NO EDUCATION/TRAINING HIGH SCHOOL Name* Address* YEAR GRADUATED* MM slash DD slash YYYY College Name Address Grade CompletedSelect1234Major Degree Received College Name Address Grade CompletedSelect1234Major Degree Rec'd Grad School Name Address Grade CompletedSelect1234Major Degree Rec'd Trade School Name Address Major Degree Rec'd ADDITIONAL CERTIFICATIONS AND/OR TRAINING OF NOTE: EMPLOYMENT HISTORYNAME OF COMPANY* CITY & STATE* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State PHONE NUMBERJOB TITLE ENDING PAY REASON FOR LEAVING EMPLOYMENT TIMEFrom (Mo. / Yr.)To (Mo. / Yr.)Total (Yrs / Mos.)MAY WE CONTACT THIS EMPLOYER? Yes No REFERENCE VERIFICATIONPlease 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 MM slash DD slash YYYY Print Name Signature Required at Interview
