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APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER

We are an equal opportunity employer and makes employment decisions on the basis of merit and without regard to race, age, color, gender, gender identity, religion, veteran status, marital status, national origin or ancestry, sexual orientation, pregnancy, physical or mental disability or medical condition unrelated to the individual’s ability to perform the job, or any other consideration made unlawful by federal, state, or local laws.

Position Applied for: Date of Application:
PERSONAL INFORMATION      
Last Name First Middle  
       
Present Address      
Street City State ZIP
       
Telephone Number


  Day Number Evening Number Are you 18 years or older? (select one)
EMPLOYMENT INFORMATION      
Are You Employed Now? (select one)
 May We Contact Your Present Employer?
  
       
Salary Desired Date You Can Start Who Referred You?  
Can You Provide Required Proof Of Your Eligibility To Work In the United States?  
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
If no, describe the functions that cannot be performed.
We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and/to skill and agility tests.
       
AVAILABILITY      
Full Time Days Hours
Part Time Days Hours   Shift
Temporary
Availability 		Days Hours
Are You Available to Work Overtime, Evenings or Weekends? If no, what days can you not work?

If hired, would you have a reliable means of transportation to and from work? 		 
       
EDUCATION Name and Location No. of Years Attended Degree Major
High School
     
College
     
Trade, Business, or
Correspondence
   
Speak, write, and understand any foreign languages? (please list)  
       
Do you have any family members currently employed by Mollie Stone’s Markets? If so please list their name(s)  
       

Have you ever applied to or worked for Mollie Stone’s before? 		If yes, when?
In Case of Emergency Notify:    
   
Name Relationship    
       
Address      
Street City State ZIP
       
 


Day Phone Evening Phone    
       

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APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT HISTORY
List below all present and past employment starting with your most recent employer (last 7 years). Account for all periods of unemployment. Complete this section even if attaching a resume.
Dates of
Employment		 Name and Address of Employer
Supervisor Name and Number 		Salary
History		 Position Title and
Responsibilities 		Reason for
Leaving

From
To
From
To
From
To
From
To
From
To

Provide the names of three business references, not related to you, whom you have known for at least one year and can give accurate information about your employment experience. Please identify the reference as a Supervisor, Peer or Subordinate. No personal references.

  Name Occupation / Business Relationship Years acquainted Business Phone Home Phone
1.
2.
3.

CRIMINAL CONVICTIONS    
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related offenses that are more than two years old need not be listed)
f yes, state name of the crimes(s), when and where convicted, and disposition of the case.
(No applicant will be denied employment solely on
the grounds of conviction of a criminal offense. The nature of the offense, the date of he offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may,
however, be considered)



PLEASE READ CAREFULLY , INITIAL EACH PARAGRAPH AND SIGN BELOW

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Mollie Stone’s Markets (the Company) to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that an offer for employment may be contingent upon passing a medical examination and/or including a drug test.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company President and Owner.

Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box that follows.

I waive receipt of a copy of any public record described in the paragraph above.

Applicant’s Signature ________________________________________________ Date _____________________________________