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To be properly evaluated, this application must be filled out completely.

Last Name

First

Middle

Social Security Number

Telephone Number

Address

City

County

State

Zip Code

How Long

Email Address

Desired Position

Desired Salary

Location

If Under 21 Years Old, Date of Birth

GENERAL INFORMATION

Do any of your Friends or Family work for this company?

Name

Relationship

Your Referral Source

Advertisement Friend Relative Employment Agency Other

Have you filed an application with this company before?

Yes No

If Yes, When & Where

Have you ever been employed by this company before?

Yes No

If Yes, When & Where

Select the days you are available to work

Sunday Monday Tuesday Wednesday Thursday Friday Saturday All

Do you object to irregular hours?

Yes No

Are you willing to travel

Yes No

Are you willing to relocate

Yes No

Do you object to working more than forty (40) hours in a work week

Yes No

Do you object to working on weekends?

Yes No

Do you prefer full time or part time

Full Time Part Time

Do you have a legal right to work in the U.S.?

Yes No

Have you ever been suspended or involuntarily terminated from a job(s)

Yes No

If so, when and why?

Have you ever been convicted of a crime?

Yes No

If so, when and for what reason

Many positions at this company require the performance of various normal and everyday duties which require the ability to communicate with customers; retrieve merchandise from overheads and under counters; hang change and remove wall ceiling signs. banners; price place merchandise on shelves; realign (face) merchandise; sweep, mop, wash and sanitize food handling equipment; inspect exterior customer area, remove debris, empty trash containers. clean gasoline/oil spills, lift up to 40 lbs. lift (stack) case beer/soda, up to 5 ft., work in walk-in cooler for extended periods; monitor gasoline deliveries and take readings from gasoline pumps; complete charge tickets and related forms, also required is the dexterity to operate cash registers, gasoline consoles and similar equipment and the mobility and ability to perform minor custodial and mechanical repairs. while the preceding physical requirements relate to normal and everyday job functions, other duties may be assigned from time to time which may have other physical demands. can you perform these job requirements? Yes No

In case of emergency or accident, who should be notified?

Name

Address

City

State

Zip

Phone Number

Relationship

EDUCATION EXPERIENCE

	Name of School		Address	Year Graduated	Degrees Earned
High School
College
Other
Other
GED Earned	Yes No
If Yes, Where		When
Check Highest Grade Completed
Grade School	High School		College	Graduate School

DRIVING INFORMATION

Do you have a driver's license

Yes No

State of Issue

License Number

Has your driver's license ever been revoked?

Yes No

If yes, when and for what reason

List driving violations if any, during the past three (3) years

EMPLOYMENT AND ARMED FORCES EXPERIENCE
(Enter Present or Most Recent Position First)

Company Name	Address	City	State	Zip

Position(s)	From MO/YR	To MO/YR	Rate of Pay		Job Duties
Position(s)	From MO/YR	To MO/YR	Starting	Ending	Job Duties



Reason for Leaving
Last Supervisor's Name
Phone Number

Company Name	Address	City	State	Zip

Position(s)	From MO/YR	To MO/YR	Rate of Pay		Job Duties
Position(s)	From MO/YR	To MO/YR	Starting	Ending	Job Duties



Reason for Leaving
Last Supervisor's Name
Phone Number

Company Name	Address	City	State	Zip

Position(s)	From MO/YR	To MO/YR	Rate of Pay		Job Duties
Position(s)	From MO/YR	To MO/YR	Starting	Ending	Job Duties



Reason for Leaving
Last Supervisor's Name
Phone Number

Company Name	Address	City	State	Zip

Position(s)	From MO/YR	To MO/YR	Rate of Pay		Job Duties
Position(s)	From MO/YR	To MO/YR	Starting	Ending	Job Duties



Reason for Leaving
Last Supervisor's Name
Phone Number

List any other experience, skills, or qualifications you feel pertinent:

Agreement

By submitting this application, you agree to the following:

I give this Company the right to make a thorough investigation of my background and to perform reference checks.
I release all persons supplying reference and/or background information and this Company from any liability for damages which might result
from the furnishing of or the use of any of this information.
I understand that no circumstances, written or oral offers of employment, or other benefits related to employment shall be viewed as
establishing an employment contract unless there is an explicit written employment contract executed solely for that purpose.
I certify that all statements contained in this application (including attachments, if any) are true to the best of my knowledge. I understand
that if any false or misleading information or omission on this application is discovered, it will be reason for rejection or dismissal.