"Employment Application Form - Price Chopper"

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PRICE CHOPPER
APPLICATION FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability or any
other legally protected status.
NAME
_________________________________________________________________________________________________
(FIRST)
(MIDDLE)
(LAST)
PRESENT ADDRESS
__________________________________________________________________________________
NUMBER
STREET
CITY
STATE
ZIP
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
(____)__________________
_________________________
ARE YOU UNDER THE AGE OF 18? YES _______NO _________
IF HIRED, ON WHAT DATE WILL YOU BE AVAILABLE TO WORK ?____________________________
DO YOU KNOW ANYONE OR HAVE ANY RELATIVES EMPLOYED BY THIS COMPANY?
YES ____ NO____
___________________________________________________________________________________
(NAME)
(RELATIONSHIP)
(WHICH LOCATION?)
EDUCATION
NAME & LOCATION
YEARS COMPLETED DID YOU GRADUATE?
DEGREE OR COURSE OF STUDY
HIGH SCHOOL
________________________ 9 10 11 12
__________________ _____________________________
____________________
__________________ _____________________________
_____________________________
COLLEGE
________________________ 1 2 3 4 5 6
__________________ _____________________________
____________________
__________________ _____________________________
_____________________________
OTHER
____________________ __________________ __________________ _____________________________
WHAT PROMPTED YOUR APPLICATION?
AGENCY
OWN ACCORD
EMPLOYEE REFERRAL
ADVERTISING
OTHER
______________________________________________________________________________________________________________
POSITION(S) APPLYING FOR:
1._______________________________________ RATE OF PAY EXPECTED $ _______________
2._______________________________________ RATE OF PAY EXPECTED $ _______________
DO YOU WANT:
FULL-TIME_________
PART-TIME__________
SPECIFY DAYS AND HOURS YOU ARE AVAILABLE TO WORK:________________________
MONDAY _____________ TUESDAY _____________ WEDNESDAY ____________ THURSDAY _____________
FRIDAY _____________ SATURDAY _____________ SUNDAY _____________
DO NOT WRITE BELOW THIS LINE
FILE NUMBER ___________________START DATE ____________________
INTERVIEWED BY ____________________
JOB CODE ___________________RATE OF PAY ___________________
PRICE CHOPPER
APPLICATION FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability or any
other legally protected status.
NAME
_________________________________________________________________________________________________
(FIRST)
(MIDDLE)
(LAST)
PRESENT ADDRESS
__________________________________________________________________________________
NUMBER
STREET
CITY
STATE
ZIP
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
(____)__________________
_________________________
ARE YOU UNDER THE AGE OF 18? YES _______NO _________
IF HIRED, ON WHAT DATE WILL YOU BE AVAILABLE TO WORK ?____________________________
DO YOU KNOW ANYONE OR HAVE ANY RELATIVES EMPLOYED BY THIS COMPANY?
YES ____ NO____
___________________________________________________________________________________
(NAME)
(RELATIONSHIP)
(WHICH LOCATION?)
EDUCATION
NAME & LOCATION
YEARS COMPLETED DID YOU GRADUATE?
DEGREE OR COURSE OF STUDY
HIGH SCHOOL
________________________ 9 10 11 12
__________________ _____________________________
____________________
__________________ _____________________________
_____________________________
COLLEGE
________________________ 1 2 3 4 5 6
__________________ _____________________________
____________________
__________________ _____________________________
_____________________________
OTHER
____________________ __________________ __________________ _____________________________
WHAT PROMPTED YOUR APPLICATION?
AGENCY
OWN ACCORD
EMPLOYEE REFERRAL
ADVERTISING
OTHER
______________________________________________________________________________________________________________
POSITION(S) APPLYING FOR:
1._______________________________________ RATE OF PAY EXPECTED $ _______________
2._______________________________________ RATE OF PAY EXPECTED $ _______________
DO YOU WANT:
FULL-TIME_________
PART-TIME__________
SPECIFY DAYS AND HOURS YOU ARE AVAILABLE TO WORK:________________________
MONDAY _____________ TUESDAY _____________ WEDNESDAY ____________ THURSDAY _____________
FRIDAY _____________ SATURDAY _____________ SUNDAY _____________
DO NOT WRITE BELOW THIS LINE
FILE NUMBER ___________________START DATE ____________________
INTERVIEWED BY ____________________
JOB CODE ___________________RATE OF PAY ___________________
LIST PRESENT EMPLOYER OR MOST RECENT EMPLOYER FIRST
( PLEASE PRINT PLAINLY )
COMPANY NAME _____________________________ SUPERVISOR _____________________________________
ADDRESS _______________________________________
DATES EMPLOYED: From _______________ To _________________
TELEPHONE _____________________________
RATE OF PAY: START ______________ LAST __________________
STATE JOB TITLE AND DESCRIBE YOUR WORK_______________________________________________________
______________________________________________________________________________________________
REASON FOR LEAVING ___________________________________________________________________________
COMPANY NAME _____________________________ SUPERVISOR _____________________________________
ADDRESS _______________________________________
DATES EMPLOYED: From _______________ To _________________
TELEPHONE _____________________________
RATE OF PAY: START ______________ LAST __________________
STATE JOB TITLE AND DESCRIBE YOUR WORK_______________________________________________________
______________________________________________________________________________________________
REASON FOR LEAVING ___________________________________________________________________________
COMPANY NAME _____________________________ SUPERVISOR _____________________________________
ADDRESS _______________________________________
DATES EMPLOYED: From _______________ To _________________
TELEPHONE _____________________________
RATE OF PAY: START ______________ LAST __________________
STATE JOB TITLE AND DESCRIBE YOUR WORK_______________________________________________________
______________________________________________________________________________________________
REASON FOR LEAVING ___________________________________________________________________________
MAY WE CONTACT THESE EMPLOYERS? YES _________ NO _________
HAVE YOU EVER BEEN CONVICTED OF, OR PLEADED GUILTY TO A FELONY? YES ______ NO _________
If yes, describe in full. Convictions will not necessarily disqualify an applicant from employment.
____________________________________________________________________________________________
Occasionally the form of an application blank makes if difficult for individuals to adequately summarize their
complete background. With that in mind please list any other special skills or qualifications that you would like us
to consider.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
IMPORTANT: READ CAREFULLY
I certify that the information contained in this application is correct to the best of my knowledge. If employed, I understand
that the falsification of this information may result in my dismissal. I authorize the investigation of all statements contained in
this application for employment as necessary in arriving at an employment decision. I understand that my employment may
be terminated, with or without notice, by the Company for any reason, including lack of work, unsatisfactory performance,
improper behavior or any other reason which, in the sole judgment of the Company, constitutes a basis for termination of
employment.
___________________________________________
Applicant's Signature
___________________________________________
Date
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