Personal Information

1. First Name:
2. Last Name:
3. Middle Initial:
4. Address:
5. City:
6. State:
7. Zip Code:
8. How long at this address:
9. Phone:
10. Emergency Phone:
11. Social Security Number:
12. Citizen of U.S.?
13. Yes No
14. Do you have a working Visa?
15. Yes No
16. Are you over 18 years old?
17. Yes No
18. If not, how old are you?

Previous Employment Record

1. Employer Name:
2. Type of Business:
3. Address:
4. Phone Number:
5. Start Date:
6. Start Duties:
7. Starting Earnings:
8. Leaving Date:
9. Leaving Duties:
10. Leaving Earnings:
11. Last immediate supervisor’s name and title:

Previous Employment Record

1. Employer Name:
2. Type of Business:
3. Address:
4. Phone Number:
5. Start Date:
6. Start Duties:
7. Starting Earnings:
8. Leaving Date:
9. Leaving Duties:
10. Leaving Earnings:
11. Last immediate supervisor’s name and title:
12. Last education completed:

Personal References (not relative or previous employers)

1. Name:
2. Address:
3. Occupation:
4. Phone:
5. New Field:
6. Name:
7. Address:
8. Occupation:
9. Phone:

Additional Information

1. Have you ever filled out an application with our company?
2. Yes No
3. Have you ever been employed in the past by our company?
4. Yes No
5. If Yes, approximate dates and location?
6. What special skills or qualifications to you posses?
7. Do you have relatives employed by Foodtown?
8. Yes No
9. Whom?
10. Do you seek full-time or part-time employment?
11. Yes No
12. How long to do wish to have part-time work for?
13. Did someone refer you to us?
14. Yes No
15. If so, Whom?
16. Are you working more than one job?
17. Yes No
18. Have you ever been convicted of a crime other than a traffic violation?
19. Yes No
20. If yes, provide the State and nature of the crime? Note: No applicant will be excluded
21. Yes No
22. Have you ever been discharged or asked to resign by any former employee?
23. Yes No
24. If yes, explain in detail?
25. Are there any employees whom you DO NOT wish us to contact?
26. Yes No

Applicant Agreement

1. In completing and signing this application for employment, I understand that misrepresentation of facts is cause for cancellation of this application or separation from the company’s service if I am employed. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers, or omissions made by me on this application. I understand further that information concerning my past record will be sought from my previous employers and other sources and I hereby release from all liability or damages those individuals, corporations, ore organizations, who provide such information. I understand any such information provided shall become the exclusive property of the company. After reading the above to indicate your agreement, choose Accept or decline.
2. Accept Decline