Moraine Pointe Giant Eagle

Today's Date *

APPLICANT CONTACT INFORMATION

First Name *

Middle Name

Last Name *

Address *

City *

State *

Zip Code *

Home Phone Number *

Example: xxxxxxxxxx

Cell Phone Number

Example: xxxxxxxxxx

Email Address

Tax District

Emergency Contact Name *

Emergency Contact Phone Number *

Example: xxxxxxxxxx

Are you 18 years of age or older? *

Yes

If 'No", please provide date of birth.

If you are under 18 years of age, do you have a work permit?

Yes

If "No", please provide the school name.

Have you or a relative ever worked for this employer? *

Yes

If "Yes", please provide name and dates of employment.

Are you available on Sundays? *

Yes

Sunday Available Start Time

Sunday End Time

Are you available on Mondays? *

Yes

Monday Available Start Time

Monday End Time

Are you available on Tuesdays? *

Yes

Tuesday Available Start Time

Tuesday End Time

Are you available on Wednesdays? *

Yes

Wednesday Available Start Time

Wednesday End Time

Are you available on Thursdays? *

Yes

Thursday Available Start Time

Thursday End Time

Are you available on Fridays? *

Yes

Friday Available Start Time

Friday End Time

Are you available on Saturdays? *

Yes

Saturday Available Start Time

Saturday End Time

What is the reason for any schedule restrictions?

Another Job

School Schedule

Personal

OtherOther

Please explain schedule restrictions.

HIGH SCHOOL EDUCATION

Name of High School *

High School Address *

High School City *

High School State * High School State

High School Zip Code *

Number of High School Years Completed *

High School Major and Degree *

COLLEGE/BUSINEESS OR TRADE SCHOOL EDUCATION #1

Name of College/Business or Trade School #1

College/Business or Trade School #1 Address

College/Business or Trade School #1 City

College/Business or Trade School #1 State College/Business or Trade School #1 State

College/Business or Trade School #1 Zip Code

College/Business or Trade School #1 Years Completed

College/Business or Trade School #1 Major and Degree

COLLEGE/BUSINESS OR TRADE SCHOOL EDUCATION #2

Name of College/Business or Trade School #2

College/Business or Trade School #2 Address

College/Business or Trade School #2 City

College/Business or Trade School #2 State College/Business or Trade School #2 State

College/Business or Trade School #2 Zip Code

College/Business or Trade School #2 Years Completed

College/Business or Trade School #2 Major and Degree

Have you ever been convicted of a felony or a misdemeanor in the last seven (7) years, including any guilty, no contest, or similar pleas, or are you currently out on bail, the subject of a current warrant for arrest, or released on your own recognizance pending trial? (Exclude any records of convictions that have been sealed, expundged, or legally eradicated, and any misdemeanor conviction for which probation was completed and the case was dismissed. *

Yes

Note: An applicant will not necessarily be disqualified for employment consideration solely because of a criminal conviction. The Company does consider the nature, date, and circumstance of the offense and whether it is relevant to the duties of the position being applied for.

If, "yes', please describe the nature of the crime(s), the date(s), and location(s) of the conviction(s), and the legal disposition(s) of the case(s) below.

REFERENCES

Please list two references other than relatives or previous employers.

REFERENCE #1

Reference #1 Name

Reference #1 Title

Reference #1 Company

Reference #1 Address

Reference #1 City

Reference #1 State Reference #1 State

Reference #1 Zip Code

Reference #1 Phone Number

Example: xxxxxxxxxx

REFERENCE #2

Reference #2 Name

Reference #2 Title

Reference #2 Company

Reference #2 Address

Reference #2 City

Reference #2 State Reference #2 State

Reference #2 Zip Code

Reference #2 Phone Number

Example: xxxxxxxxxx

MILITARY EXPERIENCE

Have you ever been in the Armed Forces? *

Yes

Are you now a member of the National Guard? *

Yes

Speciality

Date Entered

Date of Discharge

WORK EXPERIENCE #1

Please list your work experience for the past five years beginning with your most recent job held. If you were self employed, please provide the firm's name.

Employer #1 Name

Employer #1 Address

Employer #1 City

Employer #1 State Employer #1 State

Employer #1 Zip Code

Employer #1 Phone Number

Employer #1 Name of Last Supervisor

Employer #1 Employment Dates

Employer #1 Starting Pay

Employer #1 Final Pay

Employer #1 Your Last Job Title

Employer #1 Reason for Leaving (Be Specific)

Employer #1 Job Responsibilities/Skills Learned/Advancements/Promotions

WORK EXPERIENCE #2

Please list your work experience for the past five years beginning with your most recent job held. If you were self employed, please provide the firm's name.

Employer #2 Name

Employer #2 Address

Employer #2 City

Employer #2 State Employer #2 State

Employer #2 Zip Code

Employer #2 Phone Number

Employer #2 Name of Last Supervisor

Employer #2 Employment Dates

Employer #2 Starting Pay

Employer #2 Final Pay

Employer #2 Your Last Job Title

Employer #2 Reason for Leaving (Be Specific)

Employer #2 Job Responsibilities/Skills Learned/Advancements/Promotions

WORK EXPERIENCE #3

Please list your work experience for the past five years beginning with your most recent job held. If you were self employed, please provide the firm's name.

Employer #3 Name

Employer #3 Address

Employer #3 City

Employer #3 State Employer #3 State

Employer #3 Zip Code

Employer #3 Phone Number

Employer #3 Name of Last Supervisor

Employer #3 Employment Dates

Employer #3 Starting Pay

Employer #3 Final Pay

Employer #3 Your Last Job Title

Employer #3 Reason for Leaving (Be Specific)

Employer #3 Job Responsibilities/Skills Learned/Advancements/Promotions

May we contact your present employer?

Yes

Did you complete this application yourself? *

Yes

If not, who completed the application for you?

TO THE EMPLOYER: I hereby certify that all of the information contained in this application is true, correct, and complete, to the best of my knowledge. I understand and agree that any deliberate falsification or omission of relevant information contained in this application is grounds for immediate dismissal, in accordance with Company policy. I understand that regardless of the available hours I have listed on this application or the hours I may be scheduled to work, the company is not guaranteeing or promising to accommodate or continue to accommodate my request(s) and my hour and/or days I am scheduled to work and may be changed by the employer at any time. I understand that in connection with my application for employment an inquiry into my background may include but not limited to, an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I hereby authorize all previous employers or educational institutions to provide you with any and all information concerning my previous employment, educational, or personal history. I hereby release and hold harmless all parties from any liability or damage that may result from furnishing said information to you. I hereby authorize you to contact all previous employers or educational institutions for the purpose of verifying information supplied on this job application, or for the purpose of obtaining more specific information about my employment, educational, personal history or any other information the Company, at its discretion, deems relevant. I hereby release and hold harmless the Company from any liability or damage that may result from contacting said previous employers or education institutions. I hereby acknowledge that, if I become employed, I will be free to terminate my employment at any time for any reason, and that the Company retains the same rights. I understand that no Company representative has the authority to make any other contrary agreement in this regard. In exchange for the consideration of my job application by the Company, I agree that neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the owner of the Company. Both the undersigned and Company may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I also understand that (1) the Company may have a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. The Company is an Equal Opportunity Employer, and does not discriminate for purposes of employment or promotion on the basis of race, color, religion, sex, national origin, age, or physical handicap where prohibited by law. It is our policy to comply fully with laws which prohibit illegal employment discrimination, and any information requested on this application will not be used for any purpose which is prohibited by law. THE APPLICATION IS CONSIDERED ACTIVE FOR 90 DAYS. FOR CONSIDERATION AFTER 90 DAYS, YOU MUST REAPPLY. IF HIRED YOU MUST FURNISH YOUR SOCIAL SECURITY CARD AND ONE (1) OF THE FOLLOWING ITEMS WITHIN 72 HOURS OF STARTING WORK: FEDERAL, STATE, OR LOCAL GOVERNMENT PHOTO I.D. CARD, A PHOTO DRIVER'S LICENSE, U.S. MILITARY PHOTO I.D. CARD, BIRTH CERTIFICATE, U.S. PASSPORT OR STAMPED INS FORM. IF YOU ARE A HIGH SCHOOL STUDENT, YOU MUST PROVIDE A WORK PERMIT UPON STARTING EMPLOYMENT. *

I agree.

TO THE APPLICANT: Please read the above paragraph and check the check box before submitting the application to the Employer for consideration. Please address any questions you may have about anything contained in this application to the interviewer or manager.

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Moraine Pointe Giant Eagle