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Application for Employment

Last Name First Name Middle Initial
Address City State Zip Code
Home Phone # Cell/Alternate Phone # Email

Please select your current age   If under 18, please list birth date
Position Applying for Type of Employment
Expected Pay Date available to start
Days and hours available to work: (Fill in days with your available times. Please include am & pm)
  Sun Mon Tues Wed Thurs Fri Sat
  From To From To From To From To From To From To From To
AM
PM
Have you ever worked for IGA Foodliner/Market Place?
    If yes, which store When? Manager
Do any of your relatives work (or have worked) for IGA Foodliner/Market Place?
    If yes, Name of relative Relationship Store

Education


Employment History

List entire employment history, with the most current employer first. Attach additional pages if necessary.

Employer
Address Phone #
Dates Employed Supervisor
Rate of Pay (Starting) Job Title
Description of Work
Reason for Leaving May We Contact?

Employer
Address Phone #
Dates Employed Supervisor
Rate of Pay (Starting) Job Title
Description of Work
Reason for Leaving May We Contact?

Employer
Address Phone #
Dates Employed Supervisor
Rate of Pay (Starting) Job Title
Description of Work
Reason for Leaving May We Contact?

Personal References

List three people that are not related to you that we may contact for a reference.

1. Name Address
Phone Relationship Number of years known

2. Name Address
Phone Relationship Number of years known

3. Name Address
Phone Relationship Number of years known

Are you bilingual?
    If yes, what languages do you speak (other than English)
Have you ever been discharged by any company?
    If yes, explain:
Have you ever been convicted of a crime (excluding minor traffic citations)?
    If yes, explain:
Are you legally eligible for employment in the U.S.?
Are you of legal age to work in the U.S.?
Do you have any kind of medical condition that might prevent you from performing the job in which you are applying?
    If yes, explain:

I understand that Market Place has a commitment to maintain an alcohol/drug-free workplace and requires a drug screening test as part of its selection and hiring process. I further understand and agree that if I am employed, I may be required to submit to alcohol/drug testing under certain circumstances during my employment. Initial here

I hereby authorize Market Place and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment.
I release Market Place and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used.
The following is my true and complete legal name and all information is true and correct to the best of my knowledge. I agree that false or omitted information may disqualify me for employment with this company. If falsification is discovered at a later date once employed, I understand it may be grounds for dismissal.Initial here

Market Place is an Equal Opportunity Employer, and does not discriminate of the basis of Sex, Race, Color, Religion, Age, Disability, Veteran Status or National Origin.

Electronic Signature Date