Employment Application

Position Information

Position Applied For

Employment Type *

Full-Time Part-Time

Date of Application *

Personal Information

Last Name *

First Name *

Middle Initial

Street Address *

Apt/Unit

City *

State *

ZIP Code *

Phone Number *

Email Address *

Date of Birth *

At least 16 years old? *

Yes No

Authorized to work in U.S.? *

Yes No

Education

Level	School Name	Location	Years	Diploma/Degree
High School
College/Trade

Employment History (Last 3 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

Employer 3

Employer Name

Phone

Address

City, State, ZIP

Job Title

Dates Employed

Supervisor

Reason for Leaving

May we contact?

Yes No

References (1 Personal, 1 Former Employer)

Personal Reference *

Name *

Relationship *

Phone *

Years Known *

Former Employer Reference *

Name *

Company *

Phone *

Years Known *

Additional Information

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

Yes No

If yes, please describe:

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

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 this application is not a contract of employment. If hired, my employment will be "at-will," meaning either I or Lane Co. Community Grocery, Inc. may terminate employment at any time, with or without cause or notice.

Electronic Signature (Full Name) *

Date *

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

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.