Name *

First Name

Last Name

Phone *

(###)

###

####

Date of birth

MM

DD

YYYY

Date you can start *

MM

DD

YYYY

Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation? *

Yes

No

Have you ever been convicted of any felonies other than minor traffic violations during the past seven years? *

(A criminal record or a conviction of any felonies other than minor traffic violations will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.)

Yes

No

High School Graduate *

Yes

No

If required, are you willing work: *

Please select all options you are willing to work. (Please note: Some weekend availability/hours will be required. Some closing shifts may also be required.)

Saturdays

Sundays

Opening Shifts

Closing Shifts

Rotating Shifts

Overtime

Positions / Areas of Interest *

Please select ALL positions / areas of Boxed and Burlap that you are interested in working. (Please note some positions will be specific to our new location in downtown Delavan and some positions will be available at both the current and new location.)

Barista

Food Preparation (Kitchen)

Bartender

Art Instructor

If currently employed may we contact your employer? *

Yes

No

READ CAREFULLY *

I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

Date of Signature *

MM

DD

YYYY