Roxy Employment Application

Personal

First Name

Last Name

Ssn

Phone

Address 1

Address 2

City

State

Zip

Picture

Roxy prefers that you provide a photo with your application.

Criminal Record

Have you been convicted of a felony in the last 7 years, excluding misdemeanors and summary of offenses, which has not been annulled, expunged, or sealed by a court?NoYes

A conviction record will not necessarilly be a bar to employment.

If you answered yes above, please explain in full detail

Employment History

Employer 1

Start Date--

End Date--

Leave blank if still employed.

Position

Salary

Reason for Leaving

Phone

Address 1

Address 2

City

State

Zip

Employer 2

Start Date--

End Date--

Leave blank if still employed.

Position

Salary

Reason for Leaving

Phone

Address 1

Address 2

City

State

Zip