Employment Application

E-mail Address: *
Name *
Street Address *
City * State * Zip Code *
Phone Number *

Are you over the age of 18? *	Yes No
For auto-insurance reasons, are you over the age of 21? *	No Yes
Position applying for * xxx Store Location *
Rate of Pay Expected Available start date *
How did you hear about the job opening? *
Education
High School *	Highest Year Completed
College *	Number of Years Completed *
Employment
Current (or most recent) Employer *
Start Date * End Date
Job Duties * Rate of Pay *
Reason for Leaving *
Previous Employer #2 *
Start Date * End Date *
Job Duties * Rate of Pay *
Reason for Leaving *
Previous Employee #3 *
Start Date * End Date *
Job Duties * Rate of Pay *
Reason for Leaving *
Please provide any additional information you feel will be helpful to us in considering your application:
Have you ever served in the U.S. Armed Forces *	Yes No
I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false tcause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references and any other persons to answer all questions asked concerning my ability, character, reputation and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. * AGREE DISAGREE

* Required