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In the last seven years have you been convicted or charged or on probation for a criminal offence (misdemeanor or felony)? Yes No If yes, explain: _______________ ________________________________________________________________________

Are you fluent in other languages?

______

If so, please list____________________________________________________

Please list any additional skills, licensees, and/or certificates that are job related:

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

____________________________________________________________________________________ EDUCATION (attach additional pages if necessary)

School Level

Name & Location of School

Major

No. of Years

Did you graduate?

Attended.

High School

College

Trade/Corresp. School

EXPERIENCE (list below your last three employers, beginning with the most recent employer)

Previous Employer

Address/Telephone

Dates

Position/ Duties

Hours Week

Supervisor

Reason for Leaving

REFERENCES (include only individuals familiar with your work ability – do not include relatives)

Name

Phone

Name of Business/Address

Years

Known/Relationship

LUBY’S FUDDRUCKERS WILL NOT ENGAGE IN ANY EMPLOYMENT PRACTICES WHICH DISCRIMINATES AGAINST EMPLOYMENT APPLICANTS BECAUSE OF RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE OR DISABILITY.

AUTHORIZATION

HR Form No. 201(revised 09/2002, 08/2007, 09/2010) Emp App

Equal Opportunity Employer

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