Thank you for your interest in joining the Dutch Bros Team!

E m p l oy m e nt

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Dutch Bros is a proud equal opportunity employer. Our policy is to provide a respectful work environment where equal employment opportunities

are available to all applicants and employees without regard to race, color, religion, gender, pregnancy, sexual orientation, gender identity or

expression, age, national origin, physical or mental disability, veteran status, or any other characteristic protected by federal, state or local law.

E m p l oy m e nt A p p l i c a t i o n

Pos i t i o n a p p l y i n g for :

P E R SO N A L I N F O R M AT I O N

N a m e ( F i rs t M i d d l e L a s t )

Prefer re d N a m e

Te l ep h o n e N u m b er

E m a i l Ad d re s s

Stre et Ad d re s s

C i t y, Sta te, Z i p Co d e

YES NO

Have you ever worked for Dutch Bros or any of its franchisees?

If ¡°yes¡± please explain:

Are you under the age of 18?

If ¡°yes¡± can you, after employment, show proof of age?

If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Do you have reliable transportation to and from work?

AVA I L A B I L I T Y

S U N DAY

F RO M

M O N DAY

TO

F RO M

TO

T U E S DAY

F RO M

TO

W E D N E S DAY

F RO M

TO

T H U R S DAY

F RO M

F R I DAY

TO

F RO M

TO

S AT U R DAY

F RO M

I f h i re d , w h e n c o u l d yo u b e g i n wo r k ?

M O N T H / DAY / Y E A R

E D U C AT I O N

Name

C i t y, Sta te

High School

C o l l e g e O r Tra d e S c h o o l

Other

# O f Yea r s

Co m p l ete d

G PA

D e g re e / D i p l o m a

TO

E m p l oy m e nt A p p l i c a t i o n

WO R K E X P E R I E N C E

C h e c k t h i s b ox i f yo u h a v e c h o s e n to a tt a c h a r e s u m e [ ]

Co m p a ny

Pos i t i o n ; D u t i e s

( N a m e, C i t y, Sta te )

S u p er v i so r

( N a m e & Te l e p h o n e )

D a te s

E m p l oye d

(MM/YY)

Rea so n ( s )

for Lea v i n g

M a y We C o nta ct ? Y [ ] N [ ]

M a y We C o nta ct ? Y [ ] N [ ]

M a y We C o nta ct ? Y [ ] N [ ]

REFERENCES

List 3 school, wor k or person al references who we may contact. Do not list peo ple who are related to you.

H ow Lo n g H a ve Yo u

N

a

m

e

Te

l

ep

h

o

n

e

N

u

m

b

er

K n ow n Th i s Per so n ?

Re l a t i o n s h i p To Yo u

Ty p e of

Refe re n c e

[ ] School

[ ] Wo r k

[ ] Personal

[ ] School

[ ] Wo r k

[ ] Personal

[ ] School

[ ] Wo r k

[ ] Personal

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW.

ONLY APPLICATIONS THAT ARE SIGNED AND DATED ARE CONSIDERED VALID.

____ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances

(initials) for employment and that the answers given by me are true and correct to the best of my knowledge. I

further certify that I, the undersigned applicant, have personally completed (or used a preparer to complete)

this application. I understand that any omission or misstatement of material fact on this application or on

any document used to secure employment shall be grounds for rejection of this application or for immediate

discharge if I am employed, regardless of the time elapsed before discovery.

____ I understand that nothing contained in the application, or conveyed during any interview which may be

(initials) granted or during my employment, if hired, is intended to create an employment contract between me and

the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or

determinable period and may be terminated at any time, with or without prior notice, at the option of

either myself or the Company, and that no promises or representations contrary to the foregoing are binding

on the Company unless made in writing and signed by me and the Company¡¯s designated representative.

____ I understand that in compliance with federal law, if hired, I will be required to verify identity and eligibility to

(initials) work in the United States and to complete the required I-9 form.

A p p l ic a nt ¡¯s S i g n a t u re

D a te

3

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