Employment Application

🌾 Anticipated opening Spring 2025 🌾

Position Information

Employment Type *

Date of Application *

Personal Information

Last Name *

First Name *

Middle Initial

Street Address *

Apt/Unit

City *

State *

ZIP Code *

Phone Number *

Email Address *

At least 16 years old? *

Yes No

Are you under 18 years old? *

Yes No

Authorized to work in U.S.? *

Yes No

Education

High School

School Name

Location (City, State)

Years Attended

Graduated?

Yes No GED

College/Trade School

School Name

Location (City, State)

Years Attended

Degree/Certification

Employment History (Last 2 Employers)

Employer 1 (Most Recent)

Employer Name

Phone

Address

City, State, ZIP

Job Title

Dates Employed

Supervisor

Reason for Leaving

May we contact?

Yes No

Employer 2

Employer Name

Phone

Address

City, State, ZIP

Job Title

Dates Employed

Supervisor

Reason for Leaving

May we contact?

Yes No

Professional References

Reference 1 *

Name *

Relationship *

Phone *

Years Known *

Reference 2 *

Name *

Relationship *

Phone *

Years Known *

Additional Information

Have you ever been employed in retail sales or by a grocery store? *

Yes No

Do you have reliable transportation? *

Yes No

Can you work days and rotating weekends? *

Yes No

Can you perform essential functions with or without accommodation? *

Yes No

Do you have any work limitations or special skills you would like us to know about? *

Yes No

Background Check Authorization & Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize Lane Co. Community Grocery, Inc. to conduct a background check as part of the employment process. I understand that any offer of employment is contingent upon successfully passing a background check.

I understand that Lane Co. Community Grocery, Inc. may require the passing of a drug test as a condition of employment. I agree to submit to such testing if requested and understand that a positive result or refusal to test may disqualify me from employment consideration or result in termination if already employed.

I authorize Lane Co. Community Grocery, Inc. to contact my previous employers, references, and any other individuals or organizations necessary to verify the information provided in this application and to obtain information regarding my employment history, job performance, and qualifications.

Electronic Signature (Full Name) *

Date *

I agree to the terms stated above and authorize a background check and drug testing. *

Parent/Guardian Consent (Required for applicants under 18)

If you are under 18 years of age, a parent or legal guardian must complete this section.

I am the parent or legal guardian of the minor applicant named above. I have read and understand the terms of this application, including the authorization for background checks and drug testing. I hereby consent to these checks and testing as a condition of my minor child's employment with Lane Co. Community Grocery, Inc.

Parent/Guardian Printed Name

Parent/Guardian Electronic Signature

Date

I am the parent/legal guardian and I consent to the terms stated above.

Equal Opportunity Employer

Lane Co. Community Grocery, Inc. is an Equal Opportunity Employer. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected status under applicable federal, state, or local laws.