SHELL
Location: ______________________________
Employment Application
APPLICANT INFORMATION
Last Name First M.I. Date
Street Address Apartment/Unit #
City State ZIP
Phone E-mail Address
Date Available Social Security No. Desired Salary
Position Applied for
Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO
Are you available to work on a full time basis? YES NO If no, number of hours per [Link] you can work?
Will you work overtime if asked? YES NO Date available
Have you ever been convicted of a felony? YES NO If yes, explain
EDUCATION
High School Address
From To Did you graduate? YES NO Degree
College Address
From To Did you graduate? YES NO Degree
Other Address
From To Did you graduate? YES NO Degree
REFERENCES
Please list three professional references other than relatives or former employees.
Full Name Relationship
Company Phone ( )
Address
Full Name Relationship
PREVIOUS EMPLOYMENT
(List employment history for at least the last three jobs held, beginning with present or most recent employer.)
Company Phone ( )
Superviso
Address
r
Starting Ending
Job Title $ $
Salary Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a
YES NO
reference?
Company Phone ( )
Superviso
Address
r
Starting Ending
Job Title $ $
Salary Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a
YES NO
reference?
Company Phone ( )
Superviso
Address
r
Starting Ending
Job Title $ $
Salary Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a
YES NO
reference?
MILITARY SERVICE
Branch From To
Rank at Discharge Type of Discharge
If other than honorable,
explain
DISCLAIMER AND SIGNATURE
“I certify that the facts contained in the application are true and complete to the best of my knowledge and understand
that, if employed, falsified statements on this application shall be grounds for dismissal. All employees are under a 90-day
probationary period, and may be dismissed at the discretion of the employer at any time therein.
I authorize investigation of all statements herein and the references and employers listed above to give you and all
information concerning my pervious employment and any pertinent information they may have, personal, or otherwise
and release the company from liability for any damage that may result from utilization of such information.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the
American with Disabilities Act (ADA) and other federal and state laws.”
Signature Date
IMPORTANT QUESTIONS/HOURS AVAILABLE TO WORK
Name:_____________________________
1. We may in the near future require drug testing; If offered a position, would you
be willing to submit to a test for the use of illegal drugs?
YES________ NO_________
2. If offered a position, would you be willing to consent to a criminal background
check?
YES________ NO__________
3. With or without reasonable accommodation, are you willing and able to lift and
move merchandise weighing up to 50 pounds to stock shelves and coolers?
YES________ NO__________
4. Do you meet the state age requirements for employment?
YES________ NO___________
5. Our locations are non-smoking, if you smoke, are you willing to comply to only
smoking in the designated smoking area on designated breaks?
YES________ NO___________
6. If offered a position, would you be willing to comply with the company dress
code guidelines?
YES________ NO__________
Hours I Can Work
Please list the hours you are available to work, including any partial times or days.
MONDAY: __________
TUESDAY: __________
WEDNESDAY: __________
THURSDAY: __________
FRIDAY: __________
SATURDAY: __________
SUNDAY: __________
We are a twenty-four hour facility and operate seven days per week: Are there any holidays you cannot
work?
___________________________
Do you have any plans to be away from work within the next 90 days, (vacations, leaves, etc.)?
______________
THIS SCHEDULE WILL GO IN MY PERSONNEL FILE TO VERIFY HOURS AND DAYS I CAN WORK.
DATE: __________
EMPLOYEE SIGNATURE: ____________________________