Personal Information

Education and Training

High School


Graduate School

Trade School

General Information

During the last ten years, have you ever been convicted of, plead guilty to, or received probation, deferred adjudication, or any other type of alternative mehtod of supervision or correction for a felony or a misdemeanor, having a penalty of imprisonment or a fine over $500?

Employment History

Work Experience 1

Work Experience 2

Work Experience 3

Business References

Person to be notified in case of emergency

Such as additional work experience, articles/books published, activities, honors received, etc. (You may choose to omit any information that would indicate age, sex, sexual orientation, race, religion, color, national origin, or disability).


I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to be the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize all persons listed above (and on the accompanying resume, if any) to give Conomart Super Stores any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and Conomart Super Stores, from liability for any damage that may result from furnishing same to Conomart Super Stores.

I understand that Conomart Super Stores will provide workers\’ compensation insurance coverage for its employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under Conomart Super Stores workers\’ compensation insurance policy.

If employed by Conomart Super Stores, I agree to abide by the policies and procedures of Conomart Super Stores which includes Conomart Super Stores Anti-Harassment Policy. I further understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of Conomart Super Stores or myself. I further understand that no manager or representative of Conomart Super Stores other than the president of Conomart Super Stores has any authority to enter into any agreement, oral or written on behalf of Conomart Super Stores for a term of employment or to make any assurance or promise of continued employment.

I understand and agree that I may be required to take a drug and alcohol screening test. I hereby give my voluntary consent for a blood and/or urine sample to be collected from me and submitted for testing. I also consent to the release of the test result to Conomart Super Stores for its use. I understand that any positive drug or alcohol result may preclude my employment.

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