We are an Equal Opportunity Employer. All applications are considered without regard to race, color, religion,
disability, sex, national origin, age (applicable federal, state, or local regulations are considered as a basis for
employment), or any other basis protected by federal, state, or local law. The Company complies with all state Clean
Indoor Air Acts which affect our business.
This employment application is only active for 90 days. After this time period a separate application must be submitted
in order to be considered for employment. Please Print Clearly and Complete the entire application. Attach additional
sheets of paper if necessary.
The Company will provide accommodations for any individuals with visual, learning, or mental disabilities throughout the
application process. Assistance will be provided at the Applicant’s request in completing the application form. |
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| PERSONAL DATA |
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| Last Name
First Name
Middle Initial
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| Other name used in past
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| Present Address
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| City
State
Zip
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| Home Phone
Cell Phone
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| Social Security Number
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| Email Address
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| Are you legally eligible for employment in the United States?
Yes
No |
| *** FEDERAL LAW prohibits the employment of unauthorized aliens. Failure to inform the Company may result in termination of your employment. Proof of U.S. citizenship or immigration status will be required if employed. *** |
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| How did you hear about this job?
Newspaper
Referral
In-Store Ad
Other
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| If Other, please specify
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| If hired, do you have a reliable means of transporation?
Yes
No
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| If so, what is it?
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| Are you at least 14 years old?
Yes
No |
| If under 18, what is your birthdate?
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| *** Due to Local/State/Federal Laws – certain work restrictions may apply to employment of minors *** |
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| Have you been employed previously or applied for a position with our Company?
Yes
No |
| If so, when?
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| Have you been convicted of a crime, which is relevant to the specific position you are applying for, in the last 10 years?
Yes
No |
| *** The existence of a criminal record does not constitute an automatic bar to employment. *** |
| If yes, state the nature of the offense and disposition of the case. Indicate dates and place.
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| EMPLOYMENT DATA |
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Position(s) applying for?
Cashier/Clerk
Store Supervisor
Store Manager
HR/District Store Manager
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If applying for Full-Time, would you consider Part-Time until a Full-Time position becomes available?
Yes
No
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Location Desired
Minimum Salary/Wage Desired $
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| Please indicate hours and shifts you would prefer to work
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| Please indicate hours and shifts you would prefer NOT to work
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| Please indicate hours and shifts you will NOT be available to work
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Are you available to work:
Overtime?
Yes
No
Weekends?
Yes
No
Holidays?
Yes
No
Overnights?
Yes
No |
| *** Unavailability does not constitute an automatic bar to employment *** |
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Are you currently employed?
Yes
No
If hired, date you would be available to start?
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Are you willing to relocate?
Yes
No
Are you willing to work temporarily at another location?
Yes
No |
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Have you ever been discharged or asked to resign from any position?
Yes
No
If yes, please explain
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How many days have you been inexcusably absent from work during the last year (do not include absences due to
illness for yourself or an immediate family member)?
Days Missed
Days Late
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Please explain
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| EDUCATION |
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| Secondary: Select the highest level completed
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7
8
9
10
11
12
GED |
| Name of school
Location
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| College: Select the highest level completed |
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1
2
3
4+ |
| Name of school
Location
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| Degree/Major
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| *** Education information will NOT result in the disqualification of employment *** |
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| If currently in high school, are you enrolled in a recognized co-op program?
Yes
No
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| If yes, identify program and school
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Please list any classes, programs, or activities which you feel may qualify you for the position being applied for
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| WORK HISTORY |
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| Employer Name
Work Phone Number
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| Address (include City, State & Zip)
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| Supervisor Name/Title
Dates of Employment: From
To
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| Job Title
Salary: Beginning $
Ending $
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| May we contact this employer?
Yes
No |
Briefly describe duties
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| Specific reason for leaving
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| Employer Name
Work Phone Number
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| Address (include City, State & Zip)
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| Supervisor Name/Title
Dates of Employment: From
To
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| Job Title
Salary: Beginning $
Ending $
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| May we contact this employer?
Yes
No |
Briefly describe duties
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| Specific reason for leaving
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PLEASE READ THE FOLLOWING CAREFULLY, BEFORE SUBMITTING THE APPLICATION
I authorize the Company to make an investigation of all information contained in this employment application and I
release all liability from companies and corporations supplying such information.
I understand any false answers, statements, or implications made by me on this application or other required
documents shall be considered sufficient cause for denial of employment or discharge.
Upon termination of my employment for whatever reason, I release the Company from all liability for supplying any
information concerning employment to any potential employer.
I authorize the Company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any
other investigative report deemed necessary through various third party sources. As required by law, upon request
within a reasonable period of time, I will be notified as to the nature and scope of such investigations.
I hereby agree to submit to any drug/alcohol test that may be required of me, whether prior to my employment or if
employed by the Company at any time thereafter.
I understand and expressly agree that if employed by the Company, storage areas provided to me (locker, desk, etc.)
are open to investigation or search by the Company without prior notice to me.
I further understand this is an application for employment and that no employment contract is being offered.
I understand that if I am employed, such employment is for an indefinite period of time and the Company may change
wages, benefits, and conditions at any time. I understand that if I am hired my employment is at will.
In consideration for my employment by the Company, I agree to conform to the rules and regulations of the Company,
as well as any Federal, State, or Local laws, and acknowledge these rules and regulations may be changed, interpreted,
withdrawn, or added to by the Company at any time, at the Company’s sole option and without prior notice to me. I
hereby acknowledge that I have read and understand all of the above.
By submitting this application, I hereby acknowledge that I have truthfully completed the Application for Employment. I also acknowledge that I have read and understand the above listed information. |
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