Job Application

APPLICATION FORM

Please complete the form below to apply for a position with us.
Name*

First NameLast Name
Do you have a valid Driver's License?*

YesNo
Driver's License Number*
State of Issuance:

Street Address

Street Address Line 2

CityState

Zip Code
Expiration Date*

MonthDayYear
Date
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Other Phone

Area CodePhone Number
E-mail
example@example.com
Emergency Contact Name:
Emergency Phone Number:
Emergency Contact Address:

Street Address

Street Address Line 2

CityState

Zip Code
ADDRESS HISTORY

Please provide all residences in the past 7 years
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Addresses?

YesNo
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Addresses?

YesNo
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
GENERAL

It is the policy of P.A. Short Distributing Company to provide employment opportunities without regard to race, creed, color, religion, sex, national origin, sexual orientation and expression, age, disability, veterans' status, or other factor protected by applicable law.
Note: Upon request and prior to commencement of employment, you must provide documents which establish your identity and authorization to work in the United States as required by Federal Law.
Position Applying For*
Are you legally authorized to work in the United States?*

YesNo
Have you ever worked for P.A. Short Distributing Company before?*

YesNo
If yes, please list dates and position:
Do you have any friends or relatives working for P.A. Short Distributing Company*

YesNo
If yes, please give their name(s)
How did you learn about this job?
Are you willing to work overtime?*

YesNo
Do you need prior notice to work overtime?*

YesNo
Are you willing to work nights?*

YesNo
Are you willing to work weekends?*

YesNo
Are you willing to travel?*

YesNo
Are you willing to work rotating shifts?*

YesNo
Have you ever been convicted of or sentenced for any violation of the law?*

YesNo
If yes, please explain in detail below
Education
Education Type:*

GEDHigh School DiplomaCollegeOther
School Name
City
State
Are you currently attending this school?

YesNo
Did you graduate from this school?

YesNo
Graduation Date

MonthDayYear
Date
Employment History

IMPORTANT - Starting with your present or most recent employer, list in consecutive order all employment (including part-time employment) and periods of unemployment for the past 7 years.
Current/Last Employer Name
Are you currently working for this employer?

YesNo
Type of Business
Job Title
Describe work performed
Employed from (start date)

MonthDayYear
Date
Employed to (last day)

MonthDayYear
Date
Employer City
Employer State
Employer Phone Number

Area CodePhone Number
Reason for Leaving
What did you like least about your job?
Are you eligible for rehire?

YesNo
Have you ever been suspended, placed on probation, asked to resign, discharged or terminated by this employer?

YesNo
If this was a contract and/or temporary assignment, please add information for the company which employed you
Additional Employers?

YesNo
Employer Name
Are you currently working for this employer?

YesNo
Type of Business
Job Title
Describe work performed
Employed from (start date)

MonthDayYear
Date
Employed to (last day)

MonthDayYear
Date
Employer City
Employer State
Employer Phone Number

Area CodePhone Number
Reason for Leaving
What did you like least about your job?
Are you eligible for rehire?

YesNo
Have you ever been suspended, placed on probation, asked to resign, discharged or terminated by this employer?

YesNo
If this was a contract and/or temporary assignment, please add information for the company which employed you
Additional Employers?

YesNo
Employer Name
Are you currently working for this employer?

YesNo
Type of Business
Job Title
Describe work performed
Employed from (start date)

MonthDayYear
Date
Employed to (last day)

MonthDayYear
Date
Employer City
Employer State
Employer Phone Number

Area CodePhone Number
Reason for Leaving
What did you like least about your job?
Are you eligible for rehire?

YesNo
Have you ever been suspended, placed on probation, asked to resign, discharged or terminated by this employer?

YesNo
If this was a contract and/or temporary assignment, please add information for the company which employed you
Additional Employers?

YesNo
Employer Name
Are you currently working for this employer?

YesNo
Type of Business
Job Title
Describe work performed
Employed from (start date)

MonthDayYear
Date
Employed to (last day)

MonthDayYear
Date
Employer City
Employer State
Employer Phone Number

Area CodePhone Number
Reason for Leaving
What did you like least about your job?
Are you eligible for rehire?

YesNo
Have you ever been suspended, placed on probation, asked to resign, discharged or terminated by this employer?

YesNo
If this was a contract and/or temporary assignment, please add information for the company which employed you
Additional Employers?

YesNo
Employer Name
Are you currently working for this employer?

YesNo
Type of Business
Job Title
Describe work performed
Employed from (start date)

MonthDayYear
Date
Employed to (last day)

MonthDayYear
Date
Employer City
Employer State
Employer Phone Number

Area CodePhone Number
Reason for Leaving
What did you like least about your job?
Are you eligible for rehire?

YesNo
Have you ever been suspended, placed on probation, asked to resign, discharged or terminated by this employer?

YesNo
If this was a contract and/or temporary assignment, please add information for the company which employed you
Special Skills
Please summarize special job-related skills and qualifications acquired from employment or other experiences
Word Processing Packages Used
What are you career objectives?
Relate any additional information that more fully conveys your qualifications
Please list any equipment and software programs on which you are qualified and experienced in operating
Upload Resume (Optional)

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I HEREBY CERTIFY that my answers to the foregoing questions are true and complete and that I have not knowingly withheld any facts, circumstances or other information which would, if disclosed, affect my application. I understand that any false or misleading statement or omission of pertinent information will result in the rejection of my application, or in dismissal if discovered subsequent to my employment.
Signature*

Clear
Date Signed:*

MonthDayYear
Date
Should be Empty:

APPLICATION FORM

ADDRESS HISTORY

GENERAL

Education

Employment History

Special Skills