Application</tile></head>
<h2 align = center>BERRY TWIST</h2>
<h2 align = center> THE BIG CHILL, INC. </h2>
<h2 align = center> 3670 Scottsville Road </h2>
<h2 align = center> Floyds Knobs, Indiana 47119 </h2>
<h2 align = center><u>Application for part-time employment</u></h2>
<form method = post enctype = "text/plain" action = "app.aspx">
Date: <input type = "text" name = "date">
<p><input type = "checkbox" name = "m" value = "Mr.">Mr.
<input type = "checkbox" name = "m" value = "Mrs.">Mrs.
<input type = "checkbox" name = "m" value = "Miss">Miss
Social Security No. : <input type = "text" name = "ssn">
Address : <input type = "text" name = "address" size = 30>
Telephone No. : <input type = "text" name = "telephone">
Date of Birth : <intput type = "text" name = "birth">
Age : <input type = "text" name = "age">
Do you have a driver's license? <input type = "checkbox" name = "license" value = "yes">Yes
<input type = "checkbox" name = "licsnes" value = "no>No
No. of hours available for work each week : <input type = "text" name = "hours">
</p>
<br><br>
<b><u><center>Employment Record</center></u></b>
Name of Employer : <input type = "text" name = "employer1">
Location : <input type = "text" name = "location1">
Dates of Employment : <input type = "text" name = "dates1">
Name of Employer : <input type = "text" name = "employer2">
Location : <input type = "text" name = "location2">
Dates of Employment : <input type = "text" name = "dates2">
Name of Employer : <input type = "text" name = "employer3">
Location : <input type = "text" name = "location3">
Dates of Employment : <input type = "text" name = "dates3">
Parents name : <input type = "text" name = "parentsname">
<br><br>
<b><u><center>References</center></u></b>
Name : <input type = "text" name = "ref1">
Address : <input type = "text" name = "refaddr1">
Occupation : <input type = "text" name = "Occ1">
Phone No. : <input type = "text" name = "refphone1">
Name : <input type = "text" name = "ref2">
Address : <input type = "text" name = "refaddr2">
Occupation : <input type = "text" name = "Occ2">
Phone No. : <input type = "text" name = "refphone2">
Name : <input type = "text" name = "ref3">
Address : <input type = "text" name = "refaddr3">
Occupation : <input type = "text" name = "Occ3">
Phone No. : <input type = "text" name = "refphone3">
<br><br>
<b><u><center>School and Summer Activities</center></u></b>
<textarea name = "activities" rows = 3 cols = 65 wrap></textarea>
<b><u><center>Please list dates that you will not be able to work(due to vacations, etc)</center></u></b>
<textarea name = "Datesoffwork" rows = 3 cols = 65 wrap></textarea>
<br>
<p>
By clicking below you state the following:
"I hereby state that, to the best of my knowledge, the above is true and complete. Any statement made therein may be checked for validity. Any false statement will result in immediate dismissal.
</p>
<br><br>
<input type = "submit" value = "Submit">
</form>
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