Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What position are you interested in? *

Coffee Shop: Barista

Coffee Shop: Shift Leader

Mercantile: Sales Associate

Mercantile: Shift Leader

On what date can you start work?

MM

DD

YYYY

Do you have any friends, relatives, or acquaintances working for White House & Coffee Company?

YES

NO

Are you 18 years of age or older?

YES

NO

Are you a U.S Citizen or approved to work in the United States?

YES

NO

Do you have any conditions which would require job accommodations?

YES

NO

Are you military?

If yes,

Active

Inactive

Have you ever been convicted of a felony?

YES

NO