APPLICATION FOR EMPLOYMENT

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1 Present Address: Last First Middle Maiden Number Street City State Zip Social Security. Are you under 18 years of age? Position Applying For: Employment Desired: Full Time Part Time Full or Part Time Days/Hours Available: If available any hours, just mark the day with an X. Preference MON TUE WED THR FRI SAT SUN Are you available to work nights? If hired, when are you able to start? EDUCATION High School: College: Trade School: Prof. School: BACKGROUND Have you been convicted of a crime? If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

2 Do you have a Driver s License? What is your means of transportation? Driver s License: Number State of Issue Operator Commercial Expiration Date Have you had any accidents during the past three years? Have you had any moving violations during the past three years? REFERENCES Please list two references other than relatives or previous employers. How Many? How Many? Position: Company: Address: Position: Company: Address: An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

3 MILITARY Have you ever been in the Armed Forces? Are you now a member of the National Guard? Specialty: Date Entered: Discharge Date: WORK EXPERIENCE Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.

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5 May we contact your present employer? Did you complete this application yourself? If not, who did? The information contained in this application is correct to the best of my knowledge. I hereby authorize Providence Pizza LLC. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth. Signature: Print Sign Date:

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