General Information
Name
Last
First
Middle
Present address Street City State Zip
Day Phone Evening Phone Date

Please provide us your email address for confirmation:
Have you ever applied with us before? Yes     No
If yes, When? Where?
Have you ever been employed with us before? Yes     No
If yes, When? Where?
Are you eligible/authorized to work in the United States? Yes     No
Are you age 18 or older? Yes    No
How were you referred us? News Ad   Walk-in   Employee Referral   Other
Position Information
Position Applying For Salary Expected
Store Location (if applicable):
1st Choice 2nd Choice
Applying For Full Time   Part Time   Seasonal
Please Specify Days and Hours Available For Work (inability to work certain days/hours will not necessarily disqualify you from employment)
Mon Tues Wed Thurs Fri Sat Sun
Would you travel? Yes    No
Would you relocate? Yes    No
If yes, list location preference
Education Information
SCHOOL # OF YEARS COMPLETED NAME & ADDRESS OF SCHOOL GPA DID YOU GRAD? COURSE OF STUDY/MAJOR
High School Yes
No
Other Yes
No
Military Service Record
Have you ever served in the Armed Forces of The United States?
Yes    No
If yes, From     To
Branch of Service Rank at Discharge
State Duties or Specialized Training
Background Information
Within the past 7 years, have you been convicted (including pleading guilty or no contest) of a felony (this does not include expunged convictions) ? (Answering yes to this question does not necessarily mean you will be denied employment) Yes    No
If yes, please explain
During the past 5 years, have you had any periods of unemployment?
Yes    No
During the past 5 years, have you ever been discharged, Suspended or asked to resign for any reason from any position?
Yes    No
If yes, please explain
For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?
Yes    No
If yes, specify name
Employment Record
List all the employment experience for the past five years, starting with the most recent or the present emplyer if necessary, attach a seperate sheet of paper with aditional employment information. Resumes cannot be substituted for completing this employment record.
Employer Nature of Business
Address
Phone Your Title
Supervisor Supervisor's Title
From:   Month Year     To:   Month Year
Hours Worked/Week Ending Salary
Reason for leaving
Principle Responsibilities - Be complete and specific
% of Time spent in Each Area
Employer Nature of Business
Address
Phone Your Title
Supervisor Supervisor's Title
From:   Month Year     To:   Month Year
Hours Worked/Week Ending Salary
Reason for leaving
Principle Responsibilities - Be complete and specific
% of Time spent in Each Area

I hereby certify, to the best of my knowledge, that the answers given are true and complete. I also understand that an omission or falsification may disqualify me from consideration for employment or may be grounds for my immediate dismissal. I agree to conform to the rules and regulations of the company and, if employed, I understand and agree that my employment is at-will and that no employment contract rights have been created. I also understand and agree that my employment may be terminated at any time with or without cause and with or without advanced notice at the option of either the company or myself.

I understand that no supervisor, manager or other representative of the company has any authority to enter into any express or implied contract for employment for any specific period of time. Any agreement contrary to the above must be in writing and expressly state that it is a contract and be signed by the authorized representative of the company. I agree to a background check, physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the company (the aforementioned administered in accordance with state and federal laws). I also understand that employment, for certain positions, will be conditional upon successful completion of a substance abuse screening test as part of the company's pre-employment policy.

AGREE TO TERMS