Last Name
First
M.I.
Street Address
Apartment/Unit #
City
State
ZIP
Phone
E-mail Address
Date Available to Start
Desired Salary
Position Applied For
Preferred Work Type Full Time Part-Time Seasonal/Temporary
If full-time employment is unavailable, would you accept part-time or temporary employment? Yes No
Are you a citizen of the United States? Yes No
If no, are you authorized to work in the U.S.? Yes No
Are you 18 years of age or older? Yes No
Will you travel? Yes No
Have you previously filed an application with this company? Yes No
If yes, what year?
Have you ever worked for this company? Yes No
If so, when?
Have you ever been convicted of a felony or any crime other than a misdemeanor or summary offense? Yes No
If yes, explain.
Have you ever been bonded? Yes No
If yes, when and by whom?
No applicant shall be required to furnish any information of his or her first arrest for any misdemeanor or felony which did not result in a conviction, unless court action is pending. Nor shall such applicant be required to furnish information on any complaint which was dismissed for want of prosecution or which resulted in the case being continued without a finding for a certain period of time and then dismissed or which resulted in a finding or verdict of not guilty. Nor shall such applicant be require to furnish any information of arrests for the following misdemeanors, drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace; provided that the date of disposition of said offenses was five years or more prior to the filing of said application and that no applicant shall be required to furnish any information concerning any conviction of a misdemeanor which occurred more than five years prior to the date of such application for employment unless the applicant was sentenced to imprisonment upon conviction of such misdemeanor or such individual has been convicted of an offense within five years of such date.
High School
City/State
Did you graduate? Yes No
Degree
College
City/State
Did you graduate? Yes No
Degree
Business or Trade School
City/State
Did you graduate? Yes No
Degree
Other
City/State
Did you graduate? Yes No
Degree
Please list all school activities and honors (sports, plays, awards, etc.)
Full Name
Relationship
Email
Phone
Address
Full Name
Relationship
Email
Phone
Address
Full Name
Relationship
Email
Phone
Address
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? Yes No
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? Yes No
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? Yes No
Have you served in the U.S. Armed Forces? Yes No
Are you a current Reserve member? Yes No
Branch
Rank at Discharge
Type of Discharge
If other than honorable, explain.
I was referred by.
Please list any verified work experience performed on a volunteer basis.
Please list any other information that might be helpful in considering this application.
Briefly state why you want to work for this company.
Do you have any relatives or friends employed at this company? Yes No
Name and Relationship
Name and Relationship
Name and Relationship
Name
Relationship
Address
Work Phone
Home Phone
The information given on the application is true and correct to the best of my knowledge. I authorize Circle B Home Center to investigate all statements on this application. Falsification or elimination of information on this application is cause for dismissal at any time if employed. I understand that my application for employment will be processed as quickly as possible and that Public Law 91-508 requires Circle B to inform me that a routine inquiry may be made which will provide applicable information concerning character, general reputation personal characteristics and mode of living. I also understand that any employee of Circle B is free to resign at any time and is subject to termination at any time (with or without notice) and that the employment relationship is not subject to the provisions of any external documents except as expressly provided by management in writing. I hereby authorize and request any education institution to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. I am will that a photocopy of authorization be accepted with the same authority as the original. I understand that employment by Circle B makes me subject to all provisions of employment-at-will laws. I also understand that any job offers could be contingent on my passing a drug-screening test.
Our retail operation has several different types of positions. Each type has essential job functions listed below. Please respond to the questions listed under the type(s) of job(s) for which you are applying. You may apply for and be interviewed for more than one type of job.
Can you walk and stand on the job for extended periods of time—possibly up to 10 hours? Yes No
Can you consistently lift items that weigh up to 80 pounds? Yes No
Can you frequently bend, squat, reach, lift, carry, push, and pull as required when unloading trucks or stocking merchandise items? Yes No
Can you work around products such as lawn chemicals, paints, solvents, chemical cleaners and thinners? Yes No
Have you had any previous experience in selling or in dealing with people in sales related situations? Yes No
Can you work Saturdays or evenings if it is a requirement of the position? Yes No
Can you consistently lift items that weigh up to 80 pounds? Yes No
Have you ever operated motorized equipment such as forklifts? Yes No
Do you have a valid driver’s license? Yes No
Do you have a CDL? Yes No
If so, what classification?
Can you frequently bend, squat, reach, lift, carry, push, and pull as required when unloading trucks or stocking merchandise items? Yes No
Can you work Saturdays or evenings if it is a requirement of the position? Yes No
Can you work around products such as lawn chemicals, paints, solvents, chemical cleaners and thinners? Yes No
Do you have experience in handling payroll, accounts payable, accounts receivable, or general ledger on a manual or computerized system? Yes No
Do you have experience operating a cash register or handling cash transactions? Yes No
Have you ever been required to make cash deposits for a business? Yes No
Can you work Saturday or evenings if it is a requirement of the position? Yes No
Please add any comments or additional information you feel is applicable.
By submitting this application, you are stating that you understand the Circle B Home Center is legally permitted to require a physical examination, as a condition of employment, once a job offer has been made. You certify that your responses above are true and correct and that you know of no limitations which would prevent you from performing the essential job functions.
Date
