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Cirque Lodge Inc. – Application for Employment
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Winter Retreat Feb 8th – 10th 2019

Cirque Lodge Inc. – Application for Employment

Step 1 of 8

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Personal Data
Name*
First Middle Last
Phone*
Email*
SSN
Address*
Street Address City State ZIP Code
Date of Availibility
Are you a minor under age 18?
- No
- Yes
Do you have the appropriate papers?
- No
- Yes

Position & Availability
Position Applied For
Starting Salary Expectation
Position Type:
Regular / Temporary
Are you available to work all hours and days required by the position for which you have applied for?
- Yes
- No
Are you available to work overtime when needed?
- Yes
- No
Are you able to travel?
- Yes
- No
If No to any of the above, Please explain
If hired can you provide the documents required to prove that you are authorized to work in the United States?
- Yes
- No
Are you physically able to perform all of the job duties of the position for which you are applying?
- Yes
- No
If not, what can be done to accommodate your limitation?
Have you ever applied for a position with Cirque Lodge Inc?
- Yes
- No
Please Provide the Date(s)
Have you ever been convicted of a felony within the last seven years?
- Yes
- No
If Yes, list fully all charges, giving dates, places and convictions.)
Convictions of a felony shall not automatically disqualify applicants from employment
Charge Date Location Conviction

EDUCATION
Last High School

Name
Address
Grade Completed
Junior College

Name
Address
Grade Completed
Major
Degree Rec'd
College or Univ.

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
Adult education or special training:
Other name(s) under which education may be verified
SPECIAL QUALIFICATIONS
What office machines do you operate?
Typing Speed
Steno Speed

EMPLOYMENT HISTORY
Most Recent Employment
Name of Company
Type of Business
Employer Address
Street Address City State ZIP Code
Employer Phone
Job Title
Supervisor’s Name
Duties & Responsibilities (be specific)
Reason for leaving
Employment Time
From (Mo. / Yr.) To (Mo. / Yr.) Total (Yrs / Mos.)
Starting Salary
Per
Present Salary
Per
If you are currently employed, may we contact your present employer now?
- Yes
- No

EMPLOYMENT HISTORY (ctd.)
Previous Employment
Name of Company
Type of Business
Employer Address
Street Address City State ZIP Code
Employer Phone
Job Title
Supervisor’s Name
Duties & Responsibilities (be specific)
Employment Time
From (Mo. / Yr.) To (Mo. / Yr.) Total (Yrs. / Mos.)
Reason for leaving
Starting Salary
Per
Final Salary
Per
Account for breaks in employment history:

ADDITIONAL INFORMATION
Please list 3 references that may be contacted on your behalf:
1. Company Name
Address
Phone
Email
Name of Contact
2. Company Name
Address
Phone
Email
Name of Contact
3. Company Name
Address
Phone
Email
Name of Contact
Indicate specific experience or training which you feel qualifies you for the position you are applying for:
Please indicate any additional employment not shown above or any information you believe would be helpful to us.
(Do not supply information which would tend to identify you on the basis of Race, Sex, National Origin, Color, Age, Religion, Handicap or Marital Status.)
Person to be notified in case of accident or illness:
Name: Address: Telephone:

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 (Nordaz), Medazepam (Ansilan), Alprazolam (Xanax), Zolpidem (Ambien), Temazepam (Restoril), Oxazepam (Serax), Flurazepam (Dalmane)

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
Print Name
Signature Required at Interview

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Charge	Date	Location	Conviction

Last High School
Name	Address	Grade Completed

Junior College
Name	Address	Grade Completed	Major	Degree Rec'd

College or Univ.
Name	Address	Grade Completed	Major	Degree Rec'd

Step 1 of 8

Personal Data

Position & Availability

EDUCATION

SPECIAL QUALIFICATIONS

EMPLOYMENT HISTORY

EMPLOYMENT HISTORY (ctd.)

ADDITIONAL INFORMATION