APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
We appreciate your interest in our Company. Our Company is an equal employment opportunity employer. The Company’s policy is not to discriminate against any applicant or employee based on race, color, sex, religion, national origin, age, disability, or any other basis protected by applicable law. The Company also prohibits harassment of applicants or employees based on any of these protected categories.

Note to Applicants: Smoking is prohibited in all indoor areas of the Company unless designated smoking areas have been established by a particular office in accordance with applicable state and local law.

Note to all Applicants: The Company is subject to Chapters 440.01-440.60 of Title XXXI of the General Laws of Florida and is therefore covered by the state’s workers’ compensation law.
G E N E R A L I N F O R M A T I O N

Please complete all requested information.
First Name*
Middle Name
Last Name*
Are you at least 18 years old?*

YesNo
Email*
example@example.com
Location
Today’s Date*

MonthDayYear
Date
Position Applying For*
Minimum Salary Desired
Date Available for Work

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (Home)*
Please enter a valid phone number.
Telephone (Work)
Please enter a valid phone number.
Emergency Contact
Name
Emergency Contact
Phone Number
Have you ever used any other name(s) which is (are) necessary for us to know in order for us to verify your employment or educational record?

NoYes
Are you available to work overtime as needed?

YesNo
If yes, are you available?

WeekdaysWeekends
Have you previously worked for or applied for a position with the Company, in any of our offices either as an employee or through an employment agency?

YesNo
If yes, please explain when and, if employed, in what capacity:
Do you have any relatives now employed at the Company?

YesNo
If yes, state name(s) and where they are located.
Permission To Work
If hired, can you present evidence of your US Citizenship or proof of your legal right to work in the US?

YesNo
R E F E R R A L I N F O R M A T I O N
How did you learn about our Company?
W O R K E X P E R I E N C E

Please specify your complete full-time and part-time employment history, including self-employment. Begin with your most recent employer.

Company 1
Company Name
Telephone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Start

MonthDayYear
Date
Employeement End

MonthDayYear
Date
Monthly Wages Start
Monthly Wages End
Supervisor Name
Supervisor Phone Number
Please enter a valid phone number.
Job Title, and Work Responsibilities
Reason for leaving

Company 2
Company Name
Telephone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Start

MonthDayYear
Date
Employeement End

MonthDayYear
Date
Monthly Wages Start
Monthly Wages End
Supervisor Name
Supervisor Phone Number
Please enter a valid phone number.
Job Title, and Work Responsibilities
Reason for leaving

Company 3
Company Name
Telephone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Start

MonthDayYear
Date
Employeement End

MonthDayYear
Date
Monthly Wages Start
Monthly Wages End
Supervisor Name
Supervisor Phone Number
Please enter a valid phone number.
Job Title, and Work Responsibilities
Reason for leaving

END
Please explain any gaps in your employment
All employers including your current employer may be contacted to verify the information you provide. May we contact your current employer prior to any offer of employment?

YesNo
P R O F E S S I O N A L R E F E R E N C E S

Individuals not related to you. Business references preferred.

	Name	Occupation	Phone	Address	Years Known and Capacity
Reference 1
Reference 2
Reference 3

E D U C A T I O N & T R A I N I N G

Please include name, street, city, state and zip code for each school.

School

	Name and Location of School	Number of Years Completed	Degree	Type of Course/Major
Graduate
College
High School
Business / Trade / Technical

Skills
General Office Skills

TypingShorthandTelephone ConsoleData EntryFax MachinesMail EquipmentDictation TranscriptionFiling Systems10-Key Calculator
Software and Technology

MS Word™WordPerfect™PowerPoint™LOTUS 1-2-3™Excel™Paradox™ / Access™Windows™Electronic Mail ProgramsNetwareProgramming/Database ProgramsLitigation Support ProgramsDocument Management ProgramsTelecommunicationsLegal Solutions™ / Proforma™Computer Hardware
List any other office/business skills you possess which are relevant to the position you seek:
List any other software programs with which you are proficient, and any other technical skills you possess:
Do you have any other experience, skills, or qualifications which you feel would benefit our Company? If so, please explain:
Additional Employment Inquiries
If applying for a position that will include driving:
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Please note that a “Yes” answer to any of the following questions will not necessarily disqualify you from employment. Factors such as the age and time of the offense, seriousness and nature of the violation, and rehabilitation will be considered when making any employment decisions.

NOTE: Before answering this question regarding criminal convictions please refer to the instructions below if you reside or are applying for a position in California, Connecticut, District of Columbia, Georgia, Hawaii, Massachusetts or Washington.
Have you ever been arrested, convicted, pled nolo contender, had adjudication withheld or been placed on probation for a criminal offense (including any traffic violations)? Responding Yes will not automatically disqualify you from employment. Do not include convictions that were sealed or expunged pursuant to a court order.

YesNo
Please Explain Any Yes Answer
Are you currently awaiting trial for any criminal offense?

YesNo
Please Explain Any Yes Answer
Have you ever initiated an act of violence in the workplace?

YesNo
Please Explain Any Yes Answer
INSTRUCTIONS FOR ANSWERING CRIMINAL CONVICTION INQUIRY

California Applicants: Do not identify convictions under California Health & Safety Code §§11357(b) or (c), 11360(b) (formerly subdivision (c) of section 11360), 11364, 11365, or 11550 related to marijuana offenses that occurred two or more years before the instant application. Also, do not identify any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated, or any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.
Connecticut Applicants: Applicants are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes. Criminal records subject to erasure under these sections are records pertaining to a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an
absolute pardon. Any person whose criminal records have been erased pursuant to these sections is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.
District of Columbia: Do not identify convictions that are more than ten (10) years old.
Georgia Applicants: Do not identify any guilty plea that was discharged by the court under Georgia’s First Offender Act.
Hawaii Applicants: Do not answer this question at this time. You will only have to answer this question if you receive a conditional offer of employment. At that time you will be asked whether you have been convicted of a crime within the past ten (10) years.
Massachusetts Applicants: An applicant for employment with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances, or convictions. In addition, an applicant for employment may answer “no record” with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. Massachusetts applicants should not disclose information regarding first-time misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace. Finally, Massachusetts applicants should not disclose convictions for other misdemeanors where the date of conviction or the end of any period of incarceration was more than five years ago unless there have been subsequent convictions within those five years.
Washington: Do not identify any conviction that is more than ten (10) years old at the time of making this application.
Applicant's Statement & Acknowledgement

THIS APPLICATION IS NOT COMPLETE UNTIL IT IS FULLY COMPLETED, SIGNED, AND ALL STATEMENTS BELOW HAVE BEEN READ.
- I certify that all of the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire or, if hired, may result in my dismissal at any time regardless of when the false answer or omissions are discovered.
- I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Company, I will be an at-will employee, meaning that either the Company or I may end the employment
  relationship at any time with or without cause or notice. I understand that only the Managing Director of Price Chopper Inc., and no manager, supervisor, or representative of Price Chopper Inc., has the authority to enter into any
  agreement for employment for any specified period of time, or to make any agreement contrary to the at-will employment relationship, and with respect to the Managing Director, any such agreements must be in writing and are subject to approval by the Company’s Board of Directors.
- I further understand and agree that, except for employment-at-will status, if hired my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by Price Chopper Inc.,
- I understand that if I am offered employment, I may be required to sign a non-solicitation and non-disclosure agreement, as a condition of the employment.
- I understand that Price Chopper Inc. may share the information contained in this application with other Price Chopper Inc. employees for employment and administrative purposes and hereby consent to such transfer.
- I hereby authorize Price Chopper Inc. to conduct any necessary investigation regarding my background as it relates to the position I am seeking and to the extent permitted by federal, state, and local law. I agree to complete the
  requisite authorization forms for the background investigation. I hereby release all parties from any liability in connection with the provision and use of such information.
- I agree to submit to legally permissible drug testing upon an offer of employment from Price Chopper Inc. and prior to starting work. I agree that any offer of employment is contingent upon my receiving a negative test result.
- I understand and expressly agree that if employed by Price Chopper Inc., storage areas provided for me (locker, desk, etc.) are open to investigation by the Company without prior notice to me.
- I agree to undergo a pre-employment physical examination consistent with federal and state law.
- I understand that Price Chopper Inc., has an arbitration procedure governed by the Federal Arbitration Act, 9 U.S.C. sections 1 et seq. The arbitration procedure applies to claims brought by me against Price Chopper Inc. or by Price Chopper Inc. against me. I agree that any claim arising out of or relating to the application process, including, without limitation, a claim alleging unlawful discrimination and/or harassment, and any claim arising out of or relating to my employment or its termination (if I am offered and accept employment), including, without limitation, a claim of unfair business practices, unlawful employment discrimination, harassment, wrongful demotion and/or wrongful termination, will be presented to a neutral arbitrator for final and binding decision in accordance with procedures adopted by Price Chopper Inc. These procedures do not prevent me from filing a claim or charge with the Equal Employment Opportunity Commission or National Labor Relations Board. Nor do these procedures prevent me from making a claim for workers compensation benefits or unemployment insurance. I understand and agree that I may review Price Chopper Inc.'s arbitration procedures before submitting this application for employment by making a written request for a copy of those procedures from Price Chopper Inc., Orlando, Florida.
- Massachusetts’ Applicants: I understand that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
- Maryland Applicants: I UNDERSTAND THAT UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT ANY INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
THIS AGREEMENT IS A WAIVER OF ALL RIGHTS TO CIVIL COURT ACTIONS FOR A CLAIM SUBJECT TO ARBITRATION. ONLY THE ARBITRATOR, NOT A JUDGE OR JURY, WILL DECIDE THE CLAIM OR DISPUTE.
Date

MonthDayYear
Date
My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains all the understandings between the Company and me concerning the topics addressed herein, and supersedes any prior inconsistent understandings between the Company and me on such issues.

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APPLICATION FOR EMPLOYMENT

G E N E R A L I N F O R M A T I O N

Permission To Work

R E F E R R A L I N F O R M A T I O N

W O R K E X P E R I E N C E

P R O F E S S I O N A L R E F E R E N C E S

E D U C A T I O N & T R A I N I N G

Skills

Additional Employment Inquiries

Applicant's Statement & Acknowledgement