Employment Application

Personal Information

Your Name: *
Current Address: *
City: *
State: *
Zip Code: *
Home Phone: *
Date of Birth: *

Education & Activities

Highest Grade Completed: *
Grade Point Average: *
Other Education (please specify):
Class Organizations, Honors, Sports:
Other Hobbies or Activities:
Volunteer Activities:
List Any Other Qualifications: *

Most Recent Employer

Business Name:
Start Date:
End Date:
Supervisor's Name & Title:
Supervisor's Work Phone:
May We Contact Them?:
Starting Salary:
Ending Salary:
Your Duties While Working There:

Second Most Recent Employer

Business Name:
Start Date:
End Date:
Supervisor's Name & Title:
Supervisor's Work Phone:
May We Contact Them?:
Starting Salary:
Ending Salary:
Your Duties While Working There:

Position

Position Sought:
Availability: *
Shift Preference:
Days Available to Work:
Start Date:
Prior Grocery Store Experience:
Other Customer Service Experience:
Who Referred You to Us?:
Have You Ever Been Convicted of an Offense Other Than a Minor Traffic Violation?:
If Yes, Please Explain:

This information may be considered in hiring or job placement, but will not automatically disqualify you for employment.

I understand that if employed, false statements on this application shall be cause for dismissal. I further agree that I will take a physical exam prior to employment if and when requested to do so. I herby attest that all statements made herein by me are true.