East Point – Headland Drive – Store #18

Application for Employment

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard of their race, sex, age, religion, national origin, veteran status or any disability as provided in the Americans with Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

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Date *

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

EDUCATION

Name of High School You Attend or Attended *

Address of High School *

Address Line 1

Address Line 2

City

State

Zip Code

From *

To *

Did you Graduate? *

If not please explain why?

Diploma *

Name of College You Attend or Attended

Address of College

Address Line 1

Address Line 2

City

State

Zip Code

From

Did you Graduate?

If not please explain why?

Diploma

Name of Trade School you attended if any

Address

Address Line 1

Address Line 2

City

State

Zip Code

From

Are you planning to pursue further studies? *

List any scholastic honors, offices held and activities involved in during high school and college

List and describe any other school or specialized training.

MILITARY

Have you ever served in the military? *

Service Branch

Date Entered

Date Separated

Final Rank

CAPABILITY AND RELIABILITY

Have you filed any type of fraudulent claim against any of your present or past employers? *

If yes, please explain.

How many days of work (or school) have you missed in the last two years? *

How many times have you been late for work (or school) in the last two years? *

PERSONAL FITNESS STATEMENT

Are you willing to take a physical examination at the company's expense? *

Regarding the work for which you have applied, are you substantially able to perform this work safely and without hazard to yourself or others? *

In Case of Emergency, Who would you like us to notify

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Medical Information

Please list any medical information

WORK HISTORY

Employer 1

Name of Employer (1)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Starting Pay

Ending Pay

Reason for leaving?

Employer 2

Name of Employer (2)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Starting Pay

Ending Pay

Reason for leaving?

Employer 3

Name of Employer (3)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Starting Pay

Ending Pay

Reason for leaving?

SUPPLEMENTAL EMPLOYMENT INFORMATION

Name

Company

Name

Company

Are you currently employed? *

If yes, may we contact your current employer? *

Have you ever been fired or asked to resign from a job? *

If yes, please explain

Have you ever been disciplined or received verbal warnings for absenteeism or tardiness? *

If yes, please explain

SPECIAL SKILLS

Can you type? *

How many words per minute can you type?

Have you had any computer or word processing experience or training? *

If yes, please describe

What languages do you speak fluently? *

Why you are interested in working for our company? Please list any skills and abilities which you feel qualify for the position. *

REFERENCES

Reference (1)

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Occupation *

Reference (2)

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Occupation *

Reference (3)

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Occupation *

AUTHORIZATION FOR BACKGROUND CHECK

Do you authorize a background check? *

If yes, please type you full legal name below

Date *

AFFIDAVIT

Do you swear that all of your statements and answers are true? *

If yes, please type your full legal name below

East Point – Headland Drive – Store #18