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Thank you for your interest in working for Iceberg Drive Inn. For 50 years, Iceberg has been - page 4 / 4

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PERSONAL REFERENCES

NAME _______________________________

NAME _______________________________

ADDRESS ___________________________

ADDRESS ___________________________

TELEPHONE

TELEPHONE

N A M E _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A D D R E S S _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_________________________

_________________________

TELEPHONE

_________________________

DURING THE PAST 7 YEARS, HAVE YOU EVER BEEN CONVICTED OF, PLED GUILTY TO OR PLED NO CONTEST TO A CRIME, EXCLUDING MISDEMEANORS AND

TRAFFIC VIOLATIONS?

YES / NO

IF YES,DESCRIBE IN FULL

__________________________________________________________________________________

1. I certify that I have read and fully completed both sides of this application and that the information contained on this application is correct to the best of my knowledge and understand that any omission or erroneous information is grounds for dismissal in accordance with the policy of this independent Iceberg Drive-inn franchisee. 2. I authorize the references listed on this application to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. 3. I acknowledge that this independently owned and operated Iceberg Drive-inn franchisee reserves the right to amend or modify the policies in its Employee Handbook and other policies of this Iceberg Drive-inn franchisee at any time, without prior notice. These policies do not create any promises or contractual obligations between this independent Iceberg Drive-inn franchisee and its employees. At this Iceberg Drive-inn franchise, my employment is at will. This means I am free to terminate my employment at any time, for any reason, with or without cause, and this Iceberg Drive-inn franchise retains the same rights. The independent Owner/Operator of this Iceberg Drive-inn franchise is the only person who may make an exception to this, and it must be in writing and signed by the Owner/Operator. I understand that my employer is an independent Owner/Operator of an Iceberg Drive-inn franchise and that I am not employed by Iceberg Drive-inn Corporation or any of its subsidiaries. The independent Owner/ Operator of this restaurant is solely responsible for all terms, condition and any other issues concerning my employment.

This independent Iceberg Drive-inn franchise is an Affirmative Action and Equal Opportunity Employer. Various Federal, State and Local laws prohibit discrimination on account of race, color, religion, sex, age, national origin, disability or veterans status. It is this Iceberg Drive-inn franchise policy to comply fully with these laws, as applicable, and information requested on this application will not be used for any purpose prohibited by law.

I understand that as a part of the procedure for my employment application, an investigative consumer report may be made concerning my character, general reputation, personal characteristics and mode of living. Upon written request, additional disclosure concerning the complete nature and scope of the investigation will be provided. If I am denied a job based either wholly or in part because of information contained in an investigative consumer report, I will be provided the name and address of the reporting agency that supplies the information.

SIGNATURE __________________________________

DATE

___________________

THIS AREA FOR OFFICE USE ONLY

Reference checks

____________________________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date interviewed

_______________

By __________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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