Simonson

Employment Application

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
We do not discriminate in hiring, or in terms and conditions of employment, because of an individual’s race, religion, color, sex, ancestry, national origin, disability or any other status protected by law or regulation.

Date: Position Applied For: Location:

Personal Data

First Name: Last Name:

Current Address:

City: State: Zip:

Phone:

Email Address:

Best time to call to schedule an interview Morning Afternoon Evening

Age: Are you legally eligible for employment in the United States: Yes No

Do you have a checking or savings account for direct deposit? Yes No

Have you ever been employed by Simonson's before? Yes No

When: Where:

Availability

How many hours per week do you want to work? Date available to start:

What times of the day would you like to work? (Check all that apply) Days Afternoons/Evenings Nights

During what hours are you available to work?

Sunday

From

To

Monday

From

To

Tuesday

From

To

Wednesday

From

To

Thursday

From

To

Friday

From

To

Saturday

From

To

Education

Select highest level or equivalent completed.

High School: 9 10 11 12

GED received: Yes No

College or Vo-Tech: 1 2 3 4
List any degree(s)

Where

Yes No Are you currently a student? Where

Personal Data

List all positions, starting with the present or most recent job.

Employer

Address

City
State

Date hired

Phone

Date left

Last Pay Rate

Your Job Title

Supervisor's Name

Reason for Leaving: Resigned with notice Resigned without notice Termination Other

To the best of your knowledge, would this employer rehire you? Yes No

Employer

Address

City
State

Date hired

Phone

Date left

Last Pay Rate

Your Job Title

Supervisor's Name

Reason for Leaving: Resigned with notice Resigned without notice Termination Other

To the best of your knowledge, would this employer rehire you? Yes No

Employer

Address

City
State

Date hired

Phone

Date left

Last Pay Rate

Your Job Title

Supervisor's Name

Reason for Leaving: Resigned with notice Resigned without notice Termination Other

To the best of your knowledge, would this employer rehire you? Yes No

Other Information

Have you ever been discharged by an employer?
If yes, give the reason why

Have you ever been convicted of a felony?
If yes, please explain giving dates and circumstances:

Have you, or anyone under your supervision, been found to have violated a prohibition on selling tobacco to minors?

Have you, or anyone under your supervision, been found to have violated a prohibition on selling alcohol to an underage person?

Note: A conviction does not automatically disqualify a job applicant from further consideration, however, deception as to their existence or falsification of their exact nature may result in denial of employment.

Applicant's Release

I AUTHORIZE Simonson Station Stores to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I release all persons, schools, employers and law enforcement agencies supplying information concerning my background.

I CERTIFY that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or, if employed, my dismissal.
I UNDERSTAND that I will be required to successfully pass a drug screening and a background check as conditions of my employment.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT, OFFER, OR PROMISE OF EMPLOYMENT. LIKEWISE, THE COMPANY CAN TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE.

Signature Date

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