PERSONAL INFORMATION *

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Are you eligible to work in the U.S?

Yes

No

Are you at least 18 years or older? (If no, you may be required to provide authorization to work.)

Yes

No

Have you ever been terminated from employment or asked to resign by an employer?

Yes

No

Can you work any shift?

Yes

No

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

Yes

No

EMPLOYMENT DESIRED

Date you can start:

MM

DD

YYYY

REFERRAL SOURCE

How did you hear about us?

Walk In

Advertisement

Referral

Other

Have you ever worked for The Delaware Contemporary before?

Yes

No

Do you know anyone who works for The Delaware Contemporary?

Yes

No

Phone

(###)

###

####

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender Identity:

Female

Male

Transgender

Non-Binary

Other / I choose to not disclose

Race/Ethnicity (check box):

Asian

Black/African American

Hispanic/Latinx

Native American Indian, Indigenous peoples, or Alaska Native

Native Hawaiian or Other Pacific Islander

White/Caucasian

Other

Age Range (check box):

0 – 18 years

19 – 35 years

36 – 55 years

56+ years

Please read carefully before signing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for The Delaware Contemporary to hire me. If I am hired, I understand that either The Delaware Contemporary or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of The Delaware Contemporary has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to The Delaware Contemporary true and complete information on this application. No requested information has been concealed. I authorize The Delaware Contemporary to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Today's Date

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THIS DATE.

MM

DD

YYYY