Corner Market Employee Application

APPLICATION FOR EMPLOYMENT

This company considers all qualified applicants without regard to race, color, religion, national origin, sex, age, disabled veterans, or veterans from the Vietnam Era.
Date of Application

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone*
Please enter a valid phone number.
Email*
example@example.com
Position(s) Desired:
Desired Salary Range:
Available to work:*

Full TimePart-TimeTemporaryOn-CallOvertimeAny Shift
What date will you be available for work?

MonthDayYear
Date
Are you on layoff and subject to recall for another employer?

YesNo
Have you filed an application here before?

YesNo
If you have filed an application here before, what date(s)?

MonthDayYear
Date
Have you ever been employed here before?

YesNo
If you have been employed here before, what date(s)?

MonthDayYear
Date
Do you have any relatives or friends employed here?

YesNo
If you have relatives or friends employed here, please list by name and relationship.
Why did you apply for Corner Market?
What is the main reason you would be a valuable employee?
Are you legally authorized to work in the United States?

YesNo
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)?

YesNo
Are you 18 years or older?

YesNo
Have you been convicted or pled guilty or no contest to a felony or misdemeanor other than a minor traffic-related infraction?

YesNo
If yes, state the nature of the conviction or plea, the date, the court and the jurisdiction, the cause number and full explain.
Do you have any pending charges for a felony or misdemeanor?

YesNo
If yes, state the nature of the conviction or plea, the date, the court and the jurisdiction, the cause number and full explain.
A conviction, plea or pending charges will not necessarily disqualify you from consideration for employment. The effect of a conviction, plea or pending charges will be assessed with respect to time, circumstances, seriousness of the offense and job responsibilites and duties. However, your failure to list a conviction, plea or pending charge (other than those that have been annulled, expunged, sealed, pardoned, erased or impounded) will disqualify you from consideration for employment or will result in termination of employment if subsequently discovered.
Is your driver's license currently suspended?

YesNo
If driving may be required in the job for which you are applying, provide:
Driver's license no. & State
For purposes of verifying past employment and schools attended, please list any other names you have used:
EDUCATION
High School: State the name, city and state
High School: Course pursued/Degrees Granted
High School: How many years of completion?
High School: Did you Graduate?

YesNo
College: State the name, city and state
College: Course pursued/Degrees Granted
College: How many years of completion?
College: Did you Graduate?

YesNo
Business, Trade, Technical or On-Line School: State the name, city and state
Business, Trade, Technical or On-Line School: Course pursued/Degrees Granted
Business, Trade, Technical or On-Line School: How many years of completion?
Business, Trade, Technical or On-Line School: Did you Graduate?

YesNo
Identify any special job-related skills and qualifications acquired from education, employment, volunteer work, or military service.
Identify specific skills related to technology, communications, customer service, or equipment that will be helpful in performing the responsibilities of the position(s) for which you are applying
Identify the previous jobs you liked best and describe why:
Identify the previous jobs you liked least and describe why:
How did you learn of this employment opportunity?

FriendRelativeJob PostingJob HotlineJob FairWebsiteOther
If other, how did you learn of this employment opportunity?
PERSONAL REFERENCES

List two references who are NOT related to you and are NOT previous employers.
Reference #1

First NameLast Name
Reference #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #1
Please enter a valid phone number.
Reference #2

First NameLast Name
Reference #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2
Please enter a valid phone number.
EMPLOYMENT RECORD

Starting with your present or most recent job, list ALL of your employment experience, including part-time or temporary employment. Do not omit any experience. You may include job-related military service assignments and volunteer activities that reflect your qualifications for employment.
Employer #1
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Immediate Supervisor

First NameLast Name
Employment Dates: (From - To)
Salary/Hourly Rate: (Starting & Final)
Kind of work performed:
Reason for Leaving:

DischargedVoluntary ResignationInvoluntary Resignation
Employer #2
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Immediate Supervisor

First NameLast Name
Employment Dates: (From - To)
Salary/Hourly Rate: (Starting & Final)
Kind of work performed:
Reason for Leaving:

DischargedVoluntary ResignationInvoluntary Resignation
Employer #3
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Immediate Supervisor

First NameLast Name
Employment Dates: (From - To)
Salary/Hourly Rate: (Starting & Final)
Kind of work performed:
Reason for Leaving:

DischargedVoluntary ResignationInvoluntary Resignation
Employer #4
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Immediate Supervisor

First NameLast Name
Employment Dates: (From - To)
Salary/Hourly Rate: (Starting & Final)
Kind of work performed:
Reason for Leaving:

DischargedVoluntary ResignationInvoluntary Resignation
Employer #5
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Immediate Supervisor

First NameLast Name
Employment Dates: (From - To)
Salary/Hourly Rate: (Starting & Final)
Kind of work performed
Reason for Leaving:

DischargedVoluntary ResignationInvoluntary Resignation
May we contact the employers listed above?

YesNo
If no, please indicate which one(s) you do NOT wish us to contact and provide the reason why you prefer that we do not contact the employer(s).
Have you ever been permitted to resign rather than be discharged or asked to resign from any position?

YesNo
If yes, please state the employer and the reason for resignation.
APPLICANT'S STATEMENT

Please indicate that you have read and understand each paragraph of the Applicant's Statement by placing your initials beside each paragraph.
1. I completed this application and confirm all information in it is TRUE and COMPLETE to the best of my knowledge. I understand that false, misleading or omitted information may result in the rejection of my application, the revocation of an offer of employment, or discharge.*

Clear
2. I authorize investigation of all statements in this application to arrive at an employment decision. I understand that an investigation may be made and information may be obtained through interviews with personal references and past employers, a credit check, a criminal history check and/or a driver's record check. This inquiry may include information as to, among other things, my character, general reputation and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references, former employers, or others that are given in response to the inquiry. If Corner Market decides to obtain a consumer credit report, I understand that it will provide, at my request, the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of information contained in such report.*

Clear
3. I release all parties including but not limited to Corner Market, personal references, and previous or current employers, from liability for any injury or damage that may result from their furnishing information concerning me or any action Corner Market takes on the basis of such information.*

Clear
4. I understand that if I am offered a job as a condition of beginning my employment, I may be required to undergo a physical examination and drug screen, and I authorize any service provider or medical facility to furnish medical information with reference to me in conjunction with that examination and related considerations.*

Clear
5. I understand that all individuals hired must produce certain documentation to verify their identity and United States citizen status or, if aliens, their legal authorization to work in the United States. I understand that an offer of employment is contingent upon my producing the required documentation within the legal time period.*

Clear
6. I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment is not for a fixed period of time and is terminable at any time and for any reason by me or by Corner Market. I further understand that statements that may be contained in policies, practices, handbooks or other material do not create a guarantee of employment and that Corner Market has the right to modify, amend, or terminate policies, practices, benefits, representative, other than its Corporate President, Joseph Janes, has the authority to enter into any agreement for any specific period of time or to make any different agreement and that such agreement must be in writing and signed by both parties to be binding. *

Clear
7. If employed, I will sign an agreement relating to confidentiality and non-competition if required.*

Clear
8. I confirm that I am not bound by an employment contract or non-competition agreement that would be breached by any employment that Corner Market offered to me, nor am I in possession of nor will I at any time reveal to the Corner Market, under any circumstances, any proprietary or confidential information that is the subject of any contract, non-disclosure agreement or prior work relationship.*

Clear
Signature of applicant*

Clear
Date

MonthDayYear
Date
This application will NOT be considered active after 60 days.
Should be Empty:

APPLICATION FOR EMPLOYMENT

EDUCATION

PERSONAL REFERENCES

EMPLOYMENT RECORD

Employer #1

Employer #2

Employer #3

Employer #4

Employer #5

APPLICANT'S STATEMENT