Dine on Demand Application

Personal Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Phone:
E-mail:
Referred by:

Employment Desired (Dispatcher, Phone Operator, Delivery Driver)

Position Desired:
Date you can start:
Salary Desired:
Are you currently employed?	Yes | No
If so, may we inquire with your present employer?	Yes | No
Have you ever applied to Dine on Demand before?	Yes | No
If so, where and when?

Education History

	Name & location of school	Years Attended	Did you Graduate?	Subjects Studied
Grammar School			Yes No
High School			Yes No
College			Yes No
Trade, Business or Correspondence School			Yes No

General Information

Subjects of special study/research work or special training/skills
U.S. Military or Naval Service

Former Employers

List below last four employers, starting with the most recent one first.

Start Date	End Date	Name and address of employer	Salary	Position	Reason for leaving

References

Give below the names of three persons not related to you,
whom you have known at least one year.

Name	Address	Business	Years known

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed or as an independent contractor, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give Dine on Demand any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.