Name *

First Name

Last Name

Phone *

(###)

###

####

Are you legally authorized to work in the United States? *

Yes

No

COVID-19 Vaccine *

Are you vaccinated against COVID-19?

Yes

No

COVID-19 Vaccine *

If you are not currently vaccinated against COVID-19, would you be willing to get vaccinated as a condition of employment?

Yes

No

Desired hours: *

Part-Time

Full-Time

Either

What is your availability? *

Mondays (AM)

Mondays (PM)

Tuesdays (AM)

Tuesdays (PM)

Wednesdays (AM)

Wednesdays (PM)

Thursdays (AM)

Thursdays (PM)

Fridays (AM)

Fridays (PM)

Saturdays (AM)

Saturdays (PM)

Sundays (AM)

Sundays (PM)

Are you currently employed? *

Yes

No

Do you intend to continue working there?

Yes

No

When are you available to start? *

MM

DD

YYYY

May we contact this employer? *

Yes

No