(Indicates Required Field*)

POSITION APPLIED FOR:

DATE OF APPLICATION: //

How were you referred to us for employment?

NAME*

Last:

First: Middle:

Email Address:

ADDRESS*

Street:

City: State: Zip Code:

TELEPHONE NUMBER* ( ) -

If necessary, best time to call you at home is…….

May we contact you at work? ……………………… Yes No

If yes, work number ….......................................……..( ) -

and best time to call……….……………………....…

Have you ever been employed by us?* ……....…… Yes No

If yes, give dates ………………………………………. FROM / / TO / /

Are you under age 18? ……………………..……….. Yes No

If under age 18, do you have appropriate
employment or age certificates? …………..……….. Yes No

(Federal law places restrictions on employment if under age 18)

Are you legally eligible for employment in this country?* …………………………….. Yes No

(Proof of identity and legal work authorization will be required upon employment)

Are you related to anyone employed by Freedom Stores, Inc.?…….....……..………. Yes No

If yes, give name(s) and relationship to you :

(Company policy restricts employment of close relatives working in the same department and as a direct report)

Are you subject to any contract, agreement or obligation with a current or former employer
that could prohibit or restrict your employment with Freedom Stores, Inc.? ……….......…….…. Yes No

If yes, please explain:

Date available for work …………………… / /

Are you available to work …………………. FULL TIME PART TIME SHIFT WORK TEMPORARY

Will you relocate if the job requires it? ……. ……………………………………………………… Yes No

Will you travel if the job requires it? ……………………………………………………………….. Yes No

Will you work overtime if required? ………………………………………………………………... Yes No

Have you ever been convicted of a crime within the last seven years? (Applicants in California need not list convictions for marijuana-related offenses that are more than two years old) (Such conviction may be relevant if job related, but does not automatically bar you from employment) ……………… Yes No

If yes, please state the circumstances with regard to each

Driver’s License Number (if required by job) State Date expires / /

Have you ever been dismissed from employment, forced to resign,
or resigned to avoid being dismissed?…………………..…………………………… Yes No

If yes, please explain:

* Freedom Store, Inc and its related companies consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a legally protected disability, or any other legally protected status.

EMPLOYMENT HISTORY

List your last three(3) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

EMPLOYER 1

TELEPHONE

( ) -

DATES EMPLOYED

FROM / /

TO / /

ADDRESS

Street

City

State Zip Code

HOURLY RATE/ SALARY

STARTING $ PER

FINISH $ PER

JOB TITLE

REASON FOR LEAVING:

IMMEDIATE SUPERVISOR’S NAME

IMMEDIATE SUPERVISOR’S JOB TITLE

EXPLAIN GAPS OF EMPLOYMENT

MAY WE CONTACT FOR REFERENCES Yes No Later

IF NO, PLEASE EXPAIN

IF LATER, PROVIDE DATE TO CONTACT / /

EMPLOYER 2

TELEPHONE

( ) -

DATES EMPLOYED

FROM / /

TO / /

ADDRESS

Street

City

State Zip Code

HOURLY RATE/ SALARY

STARTING $ PER

FINISH $ PER

JOB TITLE

REASON FOR LEAVING:

IMMEDIATE SUPERVISOR’S NAME

IMMEDIATE SUPERVISOR’S JOB TITLE

EXPLAIN GAPS OF EMPLOYMENT

MAY WE CONTACT FOR REFERENCES Yes No Later

IF NO, PLEASE EXPAIN

IF LATER, PROVIDE DATE TO CONTACT / /

EMPLOYER 3

TELEPHONE

( ) -

DATES EMPLOYED

FROM / /

TO / /

ADDRESS

Street

City

State Zip Code

HOURLY RATE/ SALARY

STARTING $ PER

FINISH $ PER

JOB TITLE

REASON FOR LEAVING:

IMMEDIATE SUPERVISOR’S NAME

IMMEDIATE SUPERVISOR’S JOB TITLE

EXPLAIN GAPS OF EMPLOYMENT

MAY WE CONTACT FOR REFERENCES Yes No Later

IF NO, PLEASE EXPAIN

IF LATER, PROVIDE DATE TO CONTACT / /

EDUCATIONAL BACKGROUND

List the last three (3) schools attended, starting with the last one. List number of years Indicate degree or diploma earned, if any. Grade point Average or Class Rank. Major and minor field of study (if applicable)

REFERENCES

List name and telephone number of three (3) work references who are not related to you and who are not previous supervisors. If not applicable, list three (3) school or personal references who are not related to you.

List professional, trade, business or civic associations and any offices held. (You may exclude memberships,
which would reveal sex, race, religious, national origin, age, ancestry or other protected status.)

List special accomplishments, publications, awards. (You may exclude accomplishments, which would reveal sex, race, religion, national origin, age, ancestry or other protected status.)

List any additional information you would like us to consider.

APPLICANT’S CERIFICATION

Please Read Carefully, Mark Each Paragraph, and Sign Below.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application for immediate discharge if I am employed, regardless of the time elapsed before discovery.

 

I understand that this application for employment will be considered active only for the period during which the specific position applied for remains open.

 

I hereby authorize Freedom Stores, Inc. to investigate all statements made by me in connection with my application for employment. I authorize Freedom Stores, Inc. to contact my prior employers, including each of those employers listed on my application for employment, and other sources of information, regarding my background, and I hereby authorize and direct each such employer and source of information to answer any and all questions regarding my prior employment and background. I hereby indemnify Freedom Stores, Inc. each of my prior employers, and each of the other sources of information contacted and agrees to hold them harmless from any claims arising from this authorization and direction.

 

I understand that any offer of regular full-time or part-time employment or per diem or temporary employment for a specified period of time is conditioned upon the passing of a drug test.

 

I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s Executives. I understand, also, that I am required to abide by all rules and regulations of the employer.

Date / /

Applicant’s Name (print)