PERSONAL
INFORMATION
Last Name:
First Name:
Middle Name:
Phone:
Address:
City:
State:
Select
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinios
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
ZIP:
E-Mail:
Are you at least 16 yrs. of
age?
Select One
Yes
No
Are you of the legal age to
serve alcohol?
Select One
Yes
No
Do you have a legal right
to work in the United States?
Select One
Yes
No
Have you ever
been employed by: The Black-eyed Pea Restaurants?
Select One
Yes
No
If yes, which
restaurant?
Dates Employed:
Have you ever been convicted
of a felony?
Select One
Yes
No
If yes, please
provide details:
A positive
response is not an automatic bar to employment with
Black-eyed Pea Restaurants.
MISCELLANEOUS
Please specify how you found
out about our company (select one only):
Select One
Referral
Advertisement
Relative
Internet
Other
EMPLOYMENT
INTERESTS / SKILLS
Position applying for:
Salary Desired:
Date Available:
Desired Work Schedule:
Select One
Full Time
Part Time
Are you willing to work overtime?
Select One
Yes
No
Can you work
a flexible schedule?
Select One
Yes
No
If no, please
note your schedule restrictions?
Calculator experience?
Select One
Yes
No
POS experience?
Select One
Yes
No
EDUCATION
High School:
Location:
State:
Select
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinios
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Highest Grade Level:
Diploma or degree type if
earned:
High School College Graduate
Business Vocational or Other Training:
Location:
State:
Select
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinios
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Highest Grade Level:
Diploma or degree type if
earned:
EMPLOYMENT
HISTORY Please
list all jobs, beginning with your present or last employer.
Account for all periods, including unemployment, self-employment,
and any military service. If space is insufficient,
list on a separate page or additional application form .
1. Company Name & Address:
Dates:
Salary:
Hours worked per week:
Job Title:
May we contact your previous employer:
Select One
Yes
No
Supervisor (Name, Title and
Telephone Number):
Duties and Responsibilities:
Reason for leaving or wishing
to leave:
2. Company Name & Address:
Dates:
Salary:
Hours worked per week:
Job Title:
May we contact your previous employer:
Select One
Yes
No
Supervisor (Name, Title and
Telephone Number):
Duties and Responsibilities:
Reason for leaving or wishing
to leave:
3. Company Name & Address:
Dates:
Salary:
Hours worked per week:
Job Title:
May we contact your previous employer:
Select One
Yes
No
Supervisor (Name, Title and
Telephone Number):
Duties and Responsibilities:
Reason for leaving or wishing
to leave:
4. Company Name & Address:
Dates:
Salary:
Hours worked per week:
Job Title:
May we contact your previous employer:
Select One
Yes
No
Supervisor (Name, Title and
Telephone Number):
Duties and Responsibilities:
Reason for leaving or wishing
to leave:
EMPLOYMENT REFERENCES
1.Name:
Address:
Telephone Number:
Occupation:
2.Name:
Address:
Telephone Number:
Occupation:
3.Name:
Address:
Telephone Number:
Occupation:
4.Name:
Address:
Telephone Number:
Occupation:
Essential
Task Requirements for Employees
COOK
Can you walk at a rate of 0.5 miles per
hour for up to 8 hours per day?
Select One
Yes
No
Are you able to lift 40 pounds
from the floor to 44 inches up to 10 times per hour?
Select One
Yes
No
Can you read English or Spanish?
Select One
Yes
No
Can you reach and grip 20
pounds from 24-48 inches up to 200 times per hour?
Select One
Yes
No
Are you able to stand constantly
for up to 8 hours?
Select One
Yes
No
Can you carry 40 pounds for
a distance of 50 feet up to 5 times per hour?
Select One
Yes
No
Are you able to push/pull
40 pounds a distance of 2 feet up to 30 times per hour?
Select One
Yes
No
QUALITY
ASSURANCE COORDINATOR (QAC)
Can you walk at a rate of
0.5 miles per hour for up to 8 hours per day?
Select One
Yes
No
Can you reach and grip 3.5
pounds from 48 inches to 12 inches up to 125 times per
hour?
Select One
Yes
No
Are you able to stand constantly
for up to 8 hours?
Select One
Yes
No
Can you read English or Spanish?
Select One
Yes
No
SERVER
Can you walk at a rate of
1 mile per hour for up to 6-8 hours?
Select One
Yes
No
Are you able to lift 16 pounds
from 31 inches to 42 inches for up to a minimum of 12-14
times per hour?
Select One
Yes
No
Are you able to stand constantly
for up to 6-8 hours a day?
Select One
Yes
No
Can you read English or Spanish?
Select One
Yes
No
Are you 18 years of age or
older?
Select One
Yes
No
DISHWASHER
Can you walk at a rate of
.25 miles per hour for up to 8 hours?
Select One
Yes
No
Are you able to lift 40 pounds
from 35 inches to 52 inches up to 15 times per hour?
Select One
Yes
No
Can you reach and grip 2.5
pounds from 48 inches to 12 inches up to 125 times per
hour?
Select One
Yes
No
Are you able to stand for
up to 8 hours a day?
Select One
Yes
No
Can you carry 40 pounds for
a distance of 40 inches up to 15 times per hour?
Select One
Yes
No
Are you able to push/pull
8 pounds up to 15 times per hour?
Select One
Yes
No
Do you have the manual dexterity
to operate the following machinery / equipment?
Blender:
Select One
Yes
No
Glass Washer :
Select One
Yes
No
GREETER
/ CASHIER (TX only)
Can you read English or Spanish?
Select One
Yes
No
Do you have the manual dexterity
to operate the following machinery / equipment:
Calculator:
Select One
Yes
No
Cash Register :
Select One
Yes
No
Do you possess basic arithmetic
skills (i.e., addition, subtraction, multiplication,
division)?
Select One
Yes
No
Can you walk at a rate of
1 mile per hour for up to 8 hours per day?
Select One
Yes
No
Can you lift 15 pounds from
32 inches to 36 inches up to 36 inches up to 10 times
per hour?
Select One
Yes
No
Can you carry 15 pounds for
a distance of 80 feet up to 10 times per hour?
Select One
Yes
No
Are you able to stand constantly
for up to 8 hours at a time?
Select One
Yes
No
Are you able to push/pull
21 pounds up to 2 times per hour (total body)?
Select One
Yes
No
BARTENDER
Can you walk at a rate of
.25 miles per hour for up to 8 hours per day?
Select One
Yes
No
Are you able to lift 40 pounds
from 7 inches to 41 inches up to 36 inches up to 10
times per shift?
Select One
Yes
No
Can you reach and grip 1 pound from 63
inches to 33 inches up to 10 times per hour?
Select One
Yes
No
Are you able to stand constantly for up
to 8 hours a day?
Select One
Yes
No
Can you read English or Spanish?
Select One
Yes
No
Can you carry 35 pounds for a distance
of 50 feet up to once an hour?
Select One
Yes
No
Do you have the manual dexterity
to operate the following machinery / equipment:
Blender:
Select One
Yes
No
Glass Washer :
Select One
Yes
No
Are you 21 years of age or older?
Select One
Yes
No
BUS PERSON
Can you walk at a rate of 1 mile per hour
for up to 8 hours per day?
Select One
Yes
No
Are you able to lift 40 pounds from 7
inches to 43 inches up to 20 times per hour?
Select One
Yes
No
Are you able to stand for up to 8 hours
a day?
Select One
Yes
No
Can you carry 40 pounds for a distance
of 100 feet up to 20 times per hour?
Select One
Yes
No
Do you have the manual dexterity
to operate the following machinery / equipment:
Tea Machine:
Select One
Yes
No
Mop Wringer:
Select One
Yes
No
DECLARATION
I certify the information
set forth in this application for employment is true
and complete to the best of my knowledge and belief
and I agree you may investigate my statements. I understand
that any information provided in this application found
to be false will disqualify me from consideration for
employment. I further understand that if after employed,
any information provided on this application or provided
in connection with my application for employment is
found to be false, Black-eyed Pea Restaurants may terminate
my employment and I acknowledge that under such circumstances,
I shall have no cause of action or recourse against
Black-eyed Pea Restaurants based thereon. I agree to
permit all past employers to give to Black-eyed Pea
Restaurants any information concerning me and release
them, and Black-eyed Pea Restaurants, from any liability
in furnishing or collecting such information. I understand
that my employment and, if employed, my continued employment
is conditioned upon my consent to and successful completion
of a background / examination and agree to waive any
and all claims against Black-eyed Pea Restaurants in
connection with any background examination / investigation
involving my application for employment and any subsequent
employment.
I understand that the scope
of any background examination / investigation is dependent
upon the position for which I apply. A background examination/investigation
may include a seven (7) year criminal history, credit
report, driving record, reference check, education and
credential confirmation, and other background information
as permitted pursuant to the Fair Credit Reporting Act,
15U.S.C. SS 1681, et. seq., and any applicable state
Credit Reporting Acts/statutes/laws. I agree that it
I am employed by Black-eyed Pea Restaurants, my employment
is “at-will”, meaning that it is at the
will of either party, that either Black-eyed Pea Restaurants
or I may terminated my employment at any time, for any
reason, with or without notice. I understand and acknowledge
that nothing contained in this application, nor any
statements made by Black-eyed Pea Restaurants, its representatives,
management or supervisors shall constitute any promise,
guarantee or contract regarding employment. Notice:
All offers of employment are contingent upon your production
of proper documentation proving your eligibility to
work within the United States.
