Employment - Conomart Super Stores

Personal Information

Name *

Address *

Apt, suite, etc.

Country

City

State

Zip code

How Long? *

Day Phone *

Home Phone *

Position for which you are applying *

Check the following options you would consider *

Full Time

Part Time

Temporary

If part time, specify hours or days *

What is your minimum salary requirement? *

Date available for work *

Do you have any commitments to another employer that might affect your employment with us? *

Education and Training

High School

School Name *

City and State *

Degree / Major Course of Study *

Degree Received *

Yes

College

School Name

City and State

Degree / Major Course of Study

Degree Received

Yes

Graduate School

School Name

City and State

Degree / Major Course of Study

Degree Received

Yes

Trade School

School Name

City and State

Degree / Major Course of Study

Degree Received

Yes

List any other education, training, special skills or certificates/licenses that you possess related to the job

List any machines, equipment, or software programs on which you are qualified and experience in operating

List any languages that you fluently speak

Read/write

Do you have a valid driver's license in this state? *

Yes

Military experience? *

Yes

If yes, what branch?

Rank at separation

General Information

Can you, after employment, submit verification of your legal right to work permanently in the U.S.? *

Yes

Are you 16 years old or over? *

Yes

If under 18, state age

Were you previously employed by Conomart Super Stores? *

Yes

If yes, dates

List any relatives working for Conomart Super Stores

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?

Answering yes is not an automatic bar to employment but will be considered in relation to specific job requirements. *

Yes

If yes, explain

Can you perform the essential functions of the job? *

Yes

Do you require any accommodation to perform the essential functions of the job? *

Yes

If yes, explain

Employment History

List all work experience beginning with the present or most recent job

Work Experience 1

Name of Employer

Type of Business

Address

Apt, suite, etc.

Country

City

State

Zip code

Dates Employed (From-To)

Title

Name and Title of Supervisor

Phone

May we contact?

Yes

Was employment?

Part Time

Full Time

Brief description of duties

Reason for leaving

Last salary

Work Experience 2

Name of Employer

Type of Business

Address

Apt, suite, etc.

Country

City

State

Zip code

Dates Employed (From-To)

Title

Name and Title of Supervisor

Phone

May we contact?

Yes

Was employment?

Part Time

Full Time

Brief description of duties

Reason for leaving

Last salary

Work Experience 3

Name of Employer

Type of Business

Address

Apt, suite, etc.

Country

City

State

Zip code

Dates Employed (From-To)

Title

Name and Title of Supervisor

Phone

May we contact?

Yes

Was employment?

Part Time

Full Time

Brief description of duties

Reason for leaving

Last salary

Business References

Name *

Occupation / Association *

Phone *

Name *

Occupation / Association *

Phone *

Name *

Occupation / Association *

Phone *

Person to be notified in case of emergency

Name *

Phone *

Address *

Please include any other information you think would be helpful to us in considering your employment.

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).

Agreement

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.

I agree with the above statement. *

Yes

Verification *

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