Burnside Bingo - Employment Application

1605 W. Burnside St.
Sioux Falls, SD 57104
605-332-7311
www.burnsidebingo.com

Application for Employment

Date of Application:

Name:(First, Middle Initial, Last)

Street Address:

City: State: Zip:

Home Phone #: Work or Cell Phone #:

Position you are applying for:
Kitchen Floor Worker Session Manager

Type of work applying for: Full time Part time

Date available to work:

How did you hear about the position:

Days available to work: (check as many as apply)
Mon Tue Wed Thurs Fri Sat Sun

Have you ever been employed by Burnside:
Yes No

EDUCATION: Applicants may be required to provide evidence of education completed.

Type of School	Name and Location of School	Dates Attended	Graduated	Type of Diploma or Degree
College or University		From(mo/yr) To(mo/yr)	Yes or No
		From(mo/yr) To(mo/yr)	Yes or No

Technical or Vocational		From(mo/yr) To(mo/yr)	Yes or No
		From(mo/yr) To(mo/yr)	Yes or No

High School		From(mo/yr) To(mo/yr)	Yes or No
		From(mo/yr) To(mo/yr)	Yes or No

REFERENCES: Please provide three professional references. Do not list relatives.

Name:	Address:	Daytime Phone:	Occupation:

EMPLOYMENT HISTORY: Include all jobs held starting with your current or most recent postion.

Employer:	May we contact? Yes No	From: To:	Full time Part time Seasonal
Mailing Address:
Telephone Number:
Starting Salary: Ending Salary:	Title:	Immediate Supervisor's Name and title:
Description of Duties:	Reason for leaving:

Employer:	May we contact? Yes No	From: To:	Full time Part time Seasonal
Mailing Address:
Telephone Number:
Starting Salary: Ending Salary:	Title:	Immediate Supervisor's Name and title:
Description of Duties:	Reason for leaving:

Employer:	May we contact? Yes No	From: To:	Full time Part time Seasonal
Mailing Address:
Telephone Number:
Starting Salary: Ending Salary:	Title:	Immediate Supervisor's Name and title:
Description of Duties:	Reason for leaving:

Employer:	May we contact? Yes No	From: To:	Full time Part time Seasonal
Mailing Address:
Telephone Number:
Starting Salary: Ending Salary:	Title:	Immediate Supervisor's Name and title:
Description of Duties:	Reason for leaving:

Please explain any gaps in your employment history of more than three months:

GENERAL INFORMATION:

List any additional special skills or qualifications you possess, such as computer software, bilingual ability, sign language.

List any job-related volunteer experience (include your supervisor's name and phone number):

Activity:	Supervisor:	Telephone Number:

Declaration of Felony and/or Misdemeanor Charges and/or Convictions:

South Dakota Codified Laws (SDCL) pertaining to Child Care Regulations 26-6 prohibit child care by a person
convicted of child abuse, sex offense, or other felony, or whose name appears on registry - Violation as misdemeanor.

Please answer the following questions regardless of your age at the time of the offense:

Have you ever been convicted of or pled guilty or no contest to any felony? Yes No

Have you ever been investigated in connection with a charge of child abuse or neglect? Yes No

Have you ever been convicted of a crime involving either violence to persons or breech of
moral conduct (i.e. rape, sexual molestation, incest, narcotics, etc)? Yes No

If you answered yes to any of the above questions, please explain (including date of the conviction).