Employment Application:
Name (Last, First, Middle)
At Least 18 Years of Age? Yes   No
Social Security Number (111-11-1111) 
Present Street Address
Telephone number     (Include Area Code)
City
State
Zip
How Long At This Address?
Previous Street Address
How Long At This Address?
Employment Desired Full  Part Time Either
Shift Desired
Store Location
Position
Will You Work Nights/Weekends? Yes   No
Will You Work Overtime? Yes   No
Do You Have Reliable Transportation Yes   No
Have you ever worked at Bread Box before? Yes
No
If yes, when?              to
Where?
If Yes, Give Reason for Leaving
Date Left
Who Was Your Supervisor or Manager?
State Any Physical Defects Which You Feel May Require An Accommodation
If Not A U.S. Citizen or Permanent Resident, What Type Of Visa Do You Have?
Valid Drivers License? Yes   No
License No.
State Issued
Date Expires
United States Military Branch
Total Length Of Active Service
Highest Rank Or Rating Attained
Major Duties
Have You Ever Been Convicted of A Crime? (A conviction will not necessarily be a bar to employment) Yes   No
If Yes, State Name of Court, Nature of Offense, and Deposition of Case
Do You Have Any Relatives Working For Bread Box Food Stores? Yes   No
If Yes, State Name
Relationship
Are You Employed At The Present Time? Yes   No
Answering "Yes" To Questions In This Section Does Not Automatically Exclude You From Employment Consideration
Store Employees Are Required To Stand a Major Portion of the Work Day.
Do you have any restriction that would limit or prevent you from doing so?		 Yes   No
If Yes, Please Explain
Store Employees Are Required to do Considerable Amounts of Carrying and Lifting of Merchandise.
Do you have any restriction that would limit or prevent you from performing these duties?		 Yes   No
If Yes, Please Explain
Store Employees Are Required to Clean, Dust and Sweep the Facilities Daily.
Do you have any restriction that would limit or prevent you from performing these duties?		 Yes   No
If Yes, Please Explain
Education
Check Highest Grade
Completed in School		 High School
 9 10 11 12
College
 1 2 3 4
Other
Special Training / Certification  
   
Employment History, Beginning With The Most Recent
(include part time and summer experience)
1. Company Name
Type of business
Street Address
City
State
Dates of employment to
Starting salary
Leaving salary
Job title
Name of supervisor
Type of job
Reason for Leaving
Employer's phone number
(include area code)		   

2. Company Name
Type of business
Street Address
City
State
Dates of employment  ex.( 01/01/00) to
Starting salary
Leaving salary
Job title
Name of supervisor
Type of job
Reason for Leaving
Employer's phone number
(include area code)		  

3. Company Name
Type of business
Street Address
City
State
Dates of employment ex (01/01/00) to
Starting salary
Leaving salary
Job title
Name of supervisor
Type of job
Reason For Leaving
Employer's phone number
(include area code)		  

Legal
Have you ever been arrested for or convicted of a crime other than a routine traffic violation? Yes
No
If yes, date of arrest or conviction        ex (01/01/00)
Please explain

*Authorization
I understand that an investigative consumer report may be made whereby information is obtained through personal or telephone interviews with third parties, such as former employers, family members, business associates, financial sources, friends, neighbors, or others with whom I am acquainted concerning information as to my character, general reputation, personal characteristics and mode of living as the Company may determine necessary, and I consent to and authorize any person to furnish such information for such report. I further understand that I may request in writing a complete and accurate disclosure of the nature and scope of the investigation request. I further declare that all information furnished in this application, electronically signed and dated by me on this date, is true to the best of my information and belief and that any willful misrepresentation herein shall be sufficient cause for termination.

I hereby authorize the Chief of Police and/or any member of the local police department in any areas where I have lived and/or worked, or any other concerned law enforcement agency, to furnish any information concerning any criminal conviction(s) concerning me that they have on record. I hereby release the Chief of Police and/or any and all members of the police department and any other law enforcement agency wherever situated, from any and all liability resulting from the furnishing of this information.

I understand the company maintains a policy of a drug-free workplace, and that all job applicants will be drug tested. I consent and agree to a policy of random drug testing as a condition of my employment. I further agree to abide by the results of the drug test when administered by an authorized agent, thereof in absence of fraud, regardless of outcome.

I understand that nothing herein shall be deemed to create any contract of employment between me and the company, and that if I am employed as a result of this application, or otherwise, such employment shall be terminable at will, with or without notice, by me or the Company.

Yes
No

Name (as is appears on Social Security Card)
Date:

 

 

*Disclosure and Release
 
 


* Required