Stage 1: Employee creation survey - JIB 8.25.17

Full Legal Name *

Hire (today's) date *

Home restaurant *

Are you a rehire? *

Have you ever been convicted of a felony or released from prison/jail as a result of a crime for which you were convicted (felony or misdemeanor) within the last 10 years? *

A conviction will not necessarily disqualify you from employment but it is our policy to conduct a background investigation. Please explain indicating the charge, place and action taken.

How did you come to apply at Jack in the Box? *

Legal First name *

Legal Last name *

Middle initial

Suffix

Street address *

City *

State *

Zip code *

Date of birth *

Social Security Number *

Verification:

Contact Phone number 1 *

Contact Phone number 2

Email address *

Emergency contact name *

Emergency contact number *

TB clearance date *

Gender *

Ethnicity *

Were you referred by an exising employee to apply? *

If yes, what is their first & last name?

Which location do they work?

Have you worked in Hawaii, 20 hours or more for the past 14 weeks? *

Are you able to perform all essential functions of the job with or without accommodation and have you alerted your manager or company representative of any accommodations you may require? *

If No, please explain.

I would like to sign up for medical coverage? *

Select One - Enrollment Options

Medical Benefit Packages and Rates

Medical Benefit Packages and Rates

Medical Benefit Packages and Rates

Medical Benefit Packages and Rates

Spouse's Legal Name

Spouse's Social Security Number

Spouse's Date of Birth

Spouse's Sex

Enroll Child: Child's Name

Child's Social Security Number

Child's Date of Birth

Child's Sex

Enroll a second child?

Child's Legal Name

Child's Social Security Number

Child's Date of Birth

Child's Sex

Enroll a third child?

Child's Legal Name

Child's Social Security Number

Child's Date of Birth

Child's Sex

Enroll a fourth child?

Child's Legal Name

Child's Social Security Number

Child's Date of Birth

Child's Sex

Spouse's legal name

Spouse's social security number

Spouse's date of birth

Spouse's sex

Childs legal name

Child's Social Security Number

Child's Date of Birth

Child's sex

2nd Child's Legal Name

2nd Child's Social Security Number

2nd Child's Date of Birth

2nd Child's Sex

3rd Child's Legal Name

3rd Child's Social Security Number

3rd Child's Sex

3rd Child's Date of Birth

4th Child's Legal Name

4th Child's Social Security Number

4th Child's Date of Birth

4th Child's Sex

Where did you hear about us? *

Please tell us how you heard of the job.