JAMBA JUICE EMPLOYMENT APPLICATION

Personal Information

Kusumonegoro

Clarisa

Last Name

Jacqueline

First Name
Middle Name
Phone Number ( 510 ) 786 - 8234 Home Work
(
)
-
Home Work

25269 Gold Hills Drive

Address

Castro
Valley
California
City
State

1. What position are you applying for? Cash

2. Are you 16 years of age or older?

94552

Zip

Register

X Yes

No

(For team members under the age of 18 a work permit is required)

3. Have you ever worked for Jamba Juice? If yes, please list dates and location(s).

No


4. Can you submit verification of your identity and eligibility to work in the U.S.?

X Yes

No

Yes

5. Have you ever been convicted of a crime? (See note below)

No

(Do not respond concerning the following: arrests or detentions that did not result in conviction; convictions arising out of minor traffic violations; referrals to, and participation
in, any pretrial or post-trial diversion program; marijuana-related convictions more than two years old; convictions for which the record has been judicially ordered sealed,
expunged, or statutorily eradicated; and misdemeanor convictions for which probation has been successfully completed or otherwise discharged and the case has been judicially
dismissed.)

If yes, please list convictions that are a matter of public record except as stated above:

(A CONVICTION RECORD WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. Factors including but not limited to age at the time of the offense, type of offense and relevance
to the job for which you are applying, seriousness and nature of the offense, and rehabilitation will be taken into account.)

Availability (stores only)

Total available work hours per week:

10

Are you willing and available to work at any other Jamba Juice locations?
If yes, where?
Stoneridge Mall

No

Yes

license?

No

Yes

Do you own or lease a vehicle that you are willing to use for business purposes (subject to the

Yes


X No

Wed
From

To

Updated 2/14

Thurs

Fri

Sat

Sun

Mon

Tues

E

Education
School
High School

Name of School

City & State

Castro
Valley High

College (Undergrad)
Grad School
Trade, Business, Correspondence School
Other training, please specify

No

Yes

No

Yes

No

Yes

No

Employment Information
Starting with your most recent job, please list present and past employment.
All information is required .
Company name, Address and Phone
From
To
Title or position
Number
Mo/Yr Mo/Yr


Aug/
Kumon, Castro Valley,

(510)666-7890

2014

Year Degree/Major

NA
2015

Yes

CV,
CA

Graduated
Yes X
No

Starting Ending
Salary
Salary

Reason for Leaving

Present Grading Assistant $9.50/hr $9.50/hr

I want more
experience

Professional References (provide three)
Name
Relationship
Years Acquainted Phone #
Email address





dianaiskandar@gmail.com
5103295631
Diana Iskandar
18
Family friend

d
s





Pastor
5106782334
Stephen Hosea
16
shosea@gmail.com

d



510889992

btedjo@yahoo.com
George Tedjakusumo
Family
Friend
10


Applicant Statement
JAMBA JUICE IS AN EQUAL OPPORTUNITY EMPLOYER. PLEASE READ THE FOLLOWING STATEMENT CAREFULLY.
I declare under penalty of perjury that I personally completed this application and that, to the best of my knowledge, the information contained in this
application is true and /
employment and, in the event I become employed, may result in the termination of my employment if discovered a t a later date.

I understand and agree that nothing contained in this application is intended to create an employment contract between me and the company. I also
understand and agree that if I am hired, my employment with the company will be at will, and may be terminated by either me or the company at any time,
with or without cause or advance notice. I understand that no promises or representations to the contrary will be binding on the company unless made in
Kcer of the company.

I authorize the references listed above, as well as other individuals whom Jamba contacts, to provide Jamba with any and all information concerning my
previous employment and any other pertinent information. Further, I release all parties and persons from all liability from any damages that may result
from furnishing such information to Jamba as well as any use or disclosure of such information by Jamba or any of its agents, employees or representatives.

Clarisa Kusumonegoro
Applicant Signature

R S O N A L I N FOR M AT I O
Updated 2/14

July 2, 2015
Date