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1. Date: _______________

2. Name:____________________________________________________

3. Address:________________________________________

4. City _______________________ State________ Zip______________

5. Phone:_______________________________________am/pm Message:_____________________

6. Social Security Number:_________________________________

7. Check here if you are over 18___

8. Have you ever been employed by one of our stores before? (circle one) Yes / No

If Yes, Where?_____________ When?______________ Dept.?____________ Position?_________

9. List other names under which you have worked or gone to school: _____________________________________________________________

10. Have you been convicted of a felony within the last seven years?
Yes ___ No ___

11. Position Desired:_____________________________

12. Date Available: ________________________

13. What days are you available to work?_________________________

14. List any days/hours that you would not be able to work:____________

15. List your formal schooling: Including academic vocational, professional or other training:
_____________________________________________________________

16. Please identify any machines or technical equipment you may have experience with and how long:

Grocery Dept. (registers, scanning etc.)___________________________________

Meat Dept. (wrapping machine, slicers, saws)______________________________

Deli Dept. (slicers, fryers, etc.)__________________________________________

Bakery (ovens, proofers, etc.)___________________________________________

Produce Dept. (wrapping machines, etc.) __________________________________

Office (10 key, PC, Typing etc.)_________________________________________

Other (forklift, waxers, box crushers) ____________________________________

On a separate page please provide a detailed work history including Supervisor, Reason for Leaving, Dates Employed and Work Performed.

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Verification of Identity & Employment Eligibility

Federal Immigration Law requires us to verify the identity and employment eligibility of employees hired after November 6, 1986. THIS VERIFICATION MUST TAKE PLACE BEFORE YOU ARE EMPLOYED.

ALL APPLICANTS CONSIDERED FOR EMPLOYMENT WILL BE SUBJECTED TO A DRUG PRE-SCREEN

Equal Opportunity Employer

ALL APPLICANTS: This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that the information contained herein is subject to verification. I understand that if hired, my continued employment may be contingent upon the accuracy of this information. In consideration of my employment, I agree to conform to the rules and regulations of the firm and my employment and compensation can be terminated, with or without cause and with or without notice at any time at the option of either this firm or myself or in accordance with any applicable collective bargaining agreements. I understand that only the the individual store owner has the authority to enter into any written agreement to the contrary to the foregoing.

YOU MAY / MAY NOT CONTACT MY PRESENT EMPLOYER: