Personal Information
E-mail Address: *
Name: *
Social Security Number:
Street Address" *
City: *
State: * Zip Code: *
Phone Number: *
Cell Number: *
Emergency Contact:
 Relationship:
Phone Number:
   
Legal Information
Are you over the age of 18? If not, employment is subject to verification that you are of minimum legal age. *
Yes No
Can you provide legal documented proof of your eligibility for employment in the United States? Either a drivers license and Social Security Card/Birth Certificate OR Immigration and Naturalization Service Documents? *
Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *
Yes No
Have you ever been bonded? *
Yes No
Have you ever been convicted of a violation of the law other than a minor traffic violation? *
Yes No
If yes, date court and place where offense occurred.

Position / Work Information

Position applying for *
Available start date *
Store Location *
Employment Type *
What Days & Hours (part-time)
Rate of Pay Expected
Do you have any reason to believe that you would be unable to meet this companys work schedule?
 Yes No
If yes, please explain:
Have you applied for a job with us before? * Yes No
Have you ever worked for us before? * Yes No
How did you hear about the job opening? *
Education Information
Elementary School *
Graduated Yes No
Highest Year Completed
High School *
Graduated Yes No
Highest Year Completed
College*
Graduated Yes No Currently Enrolled
Number of Years Completed
Degree
Previous Employment
Previous Employer #1 *
Dates Employed*
Supervisor*
Phone*
Job Duties*
Reason for Leaving*
Rate of Pay*
Previous Employer #2 *
Dates Employed*
Supervisor*
Phone*
Job Duties*
Reason for Leaving*
Rate of Pay*
Previous Employer #3 *
Dates Employed*
Supervisor*
Phone*
Job Duties*
Reason for Leaving*
Rate of Pay*
 
Please provide any additional information you feel will be helpful to us in considering your application:
Are you currently employed? *
Yes No
If currently employed, may we contact your employer?
Yes No
If currently employed, why do you desire a change of employment?
Have you ever held a position of trust (handling money or confidential material?) *
Yes No
Have you ever served in the U.S. Armed Forces? *
 Yes No

References

Name & Relationship *
City, State *
Phone *
Name & Relationship *
City, State *
Phone *
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 (digital signature)