Order Number Last Name * First Name * M.I. Street Address * Apartment/Unit# City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP * Phone Number * Email Address * Position Applied for * Date Available * If you are under the age of 18, Please state age Referred to from what source? Earnings expected (per hour) Are you interested in Part Time/Full Time * Part Time Full Time Are you legally entitled to work in the United States * Yes No Have you ever worked for this company? * Yes No Do you have friends or relatives employed at the store? * Yes No Sunday Wednesday Saturday Monday Thursday Tuesday Friday EDUCATION High School City/State Did you Graduate? Yes No Degree College City/State Did you Graduate? Yes No Degree Other Education City/State Did you Graduate? Yes No Degree MILITARY SERVICE Branch Rank at Discharge Duties PREVIOUS EMPLOYMENT Company Name City/State Phone Number Supervisor Job Title Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes No REFERENCES Please list three references, not related to you, who have known you for at least one year. REFERENCE 1 Full Name * City/State * Relationship * Phone * REFERENCE 2 Name City/State Relationship Phone REFERENCE 3 Name City/State Relationship Phone
