First Name: Last Name: Middle Initial: Phone Number:

Present Address
No.: Street: City: State: Zip Code:

Are you at least 18 years old?    Yes   No If not, how old?

If under 18, do you have working papers?   Yes   No   Certificate Number:   Date:

Social Security Number:

Position Applied For: Rate of Pay Expected:

Would you work:       Full Time   Part Time

Hours you can work:

Monday: to Tuesday: to Wednesday: to Thursday: to Friday: to
Saturday: to Sunday: to

Do you know of any restrictions, personal or otherwise, which would restrict the hours you can work?    Yes    No

If yes, please explain:

Were you previously employed by this store or an affiliated store?   Yes    No    If yes, when and where:

List any friends or relatives working for us:

Name: How Related:

Name: How Related:

Are you prevent from lawfully beginning employment in this country because of Visa or immigration status?    Yes    No **Proof of citizenship or immigration status will be required upon employment.**

Have you ever been convicted of a crime other than a traffic violation?    Yes    No

If yes, state nature of crime:

Summarize special skills and qualification acquired from employment, education or other experience:

Education

High School    Name and Location   Highest Grade Completed:  Degree or Diploma: Major:

College Name and Location: Highest Grade Completed: Degree or Diploma: Major:

Other: Highest Grade Completed: Degree or Diploma: Major:

 

Beginning with your most recent position list all present and past employment:

Company Name: Employed From: to Address: Phone: Type of Business: Name of Supervisor: Your Title: Describe Major Functions of Your Job: Reason for Leaving:

Company Name: Employed From: to Address: Phone: Type of Business: Name of Supervisor: Your Title: Describe Major Functions of Your Job: Reason for Leaving:

Company Name: Employed From: to Address: Phone: Type of Business: Name of Supervisor: Your Title: Describe Major Functions of Your Job: Reason for Leaving:

May we contact the employers listed above?    Yes  No   If not, indicate by number which one(s) you do not wish us to contact:

Have you ever been discharged or asked to resign by any former employer?   Yes  No If yes please explain:

Unemployment History: Please list dates and explain any period of unemployment:

Terms of Agreement by hitting submit: I agree that all information in this application is true and authorized the company to investigate all statements concerning my character, reputation and work history. I understand that any offer of employment may be contingent on my passing a drug screen and/or a post-offer medical examination. It is understood that any misrepresentation by me of facts required on this application will be sufficient cause for non-employment or immediate dismissal from the company should I have been employed. I agree to conform to the policies and rules of the company, and understand that my employment and compensation are at the will of the company. All applicants will be required to furnish proof of identity and legal work authorized prior to hire.