Good Time Stores

Positions Available

TO APPLICANT: The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination on the basis of age respect to certain individuals as well as discrimination on the basis of a physical or mental disability. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry or marital status. You must be over 18 years of age to be considered for employment.

Personal Information (Please Print)

Last Name: First Name: M.I.: SSN: --

Present Address: City: State: Zip:

Telephone Number: --E-mail:

Previous Address: City: State: Zip:

Position(s) applied for: Full time Part time

If part time specify days/hours: Rate of pay expected: $/

Have you worked for us before? Yes No If YES, when?

Indicate special qualifications or skills:

Education

Name and Location of School	Course of Study	No. of Years Completed	Did You Graduate?	Degree
High School:

College:

Other:

Miscellaneous

Are you 21? Yes No (If NO, applicant is subject to minimum legal age verification.)

Have you ever been bonded? Yes No If YES, list jobs:

Have you ever been convicted of a crime within the past ten years (excluding misdemeanors and traffic offenses)? Yes No If YES, list convictions:

(Conviction for a felony or misdeanor will not necsessarily be a bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.)

The attached job description sets forth specific job duties for the position for which you are applying. Can you perform the listed duties, with or without accomodation? Yes No If NO, please identify the duties which you are unable to perform.

(Applicants will not necessarily be disqualified if they are unable to perform a particular job duty.)

If any of the duties set forth in the attached job description may be performed only with accomodation, please indicate which duties, how you would perform those duties, and what accommodation(s) you will need.

Can you meet the attendance requirements of the position? Yes No

Are you a U.S. citizen? Yes No

If not, are you a lawfully immigrated alien who is legally eligible to work? Yes No

If YES, can you provide documentation upon employment? Yes No

Military (Complete this section if you served in the U.S. Armed Forces)

Describe your duties and any special training	Branch of Service
	Period of Active Duty (Month/Year)
	From: To:
	Date of Final Discharge: //

Employment (List most recent employers first)

Position 1:
From: (Month/Year)	Employer Name:	Starting Salary: $	Ending Salary: $
To: (Month/Year)	Address:	Positions and Duties:
Telephone Number: --	Name of Supervisor:
Reason for Leaving:

Position 2:
From: (Month/Year)	Employer Name:	Starting Salary: $	Ending Salary: $
To: (Month/Year)	Address:	Positions and Duties:
Telephone Number: --	Name of Supervisor:
Reason for Leaving:

Position 3:
From: (Month/Year)	Employer Name:	Starting Salary: $	Ending Salary: $
To: (Month/Year)	Address:	Positions and Duties:
Telephone Number: --	Name of Supervisor:
Reason for Leaving:
Indicate by number any of the above employers whom you do not wish us to contact at this time: Also indicate use of any other name, if necessary, for verification of education or work history:

Acceptance

The information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal.

I understand that acceptance of this offer of employment does not create obligation upon the employer to continue to employ me in the future and that employment is strictly on an at-will basis.

Date: //

I understand and accept the conditions stated in this application: