Fillable Printable Big Lots Application Form
Fillable Printable Big Lots Application Form
Big Lots Application Form
Name (Last, First, Middle) Contact Phone Number
Street Address
City State Zip E-mail Address
Position(s) interested in?
Salary Requirements Are you under the age of 18? Yes No
Hour/Year (Circle One) If yes, state your age.
Have you ever worked for Big Lots before? Yes No
If yes, when and where?
If hired, can you supply proof that you are legally entitled to work in the United States for any employer? Yes No
Do you have friends or relatives working for us? Yes No
If so, who?
Can you work: Anytime Days Evenings Weekends
Are there any times or days you cannot work?
Have you ever been convicted of (1) a violent crime (i.e., assault, battery, murder, etc.), (2) a retail related crime (i.e., shoplifting, credit card fraud, robbery, theft,
burglary, etc.), or (3) drug trafficking/distribution? Yes No
Note: A “yes” response will not automatically disqualify you from employment, but will be considered as part of your overall job-related qualifications for
employment. You do not need to disclose any information regarding arrests or any criminal charges and/or convictions that have been erased, annulled, sealed
and/or expunged from your record.
If yes, please describe:
BIG LOTS
EMPLOYMENT APPLICATION
This application is considered active for ninety (90) days.
DRUG-FREE WORKPLACE
All employees are subject to drug and alcohol testing
procedures permitted under federal and state law.
WOTC Registration #
PERSONAL DATA
Please complete in ink.
EDUCATION
Type of School Name of School Location of School Area of Study
Last Year Did You Earn a
Completed Degree or Diploma?
High School 1 2 3 4 Yes No
College 1 2 3 4 Yes No
Graduate 1 2 3 4 Yes No
Other 1 2 3 4 Yes No
REFERENCES
List names of three people (other than relatives) we may contact who have knowledge of your job-related skills.
Name Telephone Contact/E-mail Contact Address/City/State Occupation
1
2
3
AN EQUAL OPPORTUNITY EMPLOYER
Big Lots is an Equal Opportunity Employer and does not discriminate in making employment decisions based upon race,
color, sex, religion, national origin, age, disability, marital status, sexual orientation, or veteran or military status.
SOS SKU# 960600043 • 08/12
CONTINUED ON BACK
EMPLOYMENT HISTORY
BEGINNING WITH YOUR MOST RECENT EMPLOYER, LIST ALL EMPLOYMENT INCLUDING MILITARY SERVICE AND SELF-EMPLOYMENT. Please account
for all periods of unemployment. All sections of this application must be complete even if a resume is attached.
If presently employed, may we contact your employer for references? Yes No May we contact you at your place of employment? Yes No
I understand that Big Lots may contact the past employers and/or personal references I have provided in order to verify my past employment and
work record. I authorize all past employers, educational institutions, government agencies and/or personal references to release any and all information
concerning my past employment work history, performance, and personal character. I hereby release all such employers, personal references, and Big
Lots from any and all liability resulting from damages I may incur in the reference verification process. I understand that my employment or continued
employment is contingent upon my successfully completing both reference and background checks.
I also understand that if employed by Big Lots, my employment is “at will” and can be terminated at any time for any reason either by myself or the
Company. This agreement cannot be modified by any representative of the Company either in writing or verbally.
Finally, I understand it is unlawful for Big Lots to employ anyone who is neither a citizen of the U.S. nor an alien authorized to work in the U.S. I certify
that any U.S. citizenship/work authorization information I provide to the Company is authentic. Further, I certify that all information I have provided on this
application is accurate.
False information or omission of facts on this application may result in the termination of my employment with Big Lots.
Applicant’s Signature Date
Thank you for your interest and the time you have taken to submit this application.
Name of present or last employer
Address
City, State, ZIP
Phone Number ( )
Job Title/Responsibilities
Was your position Full time Part time
Reason for leaving Terminated Voluntary Involuntary
Explain
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
Name of previous employer
Address
City, State, ZIP
Phone Number ( )
Name of previous employer
Address
City, State, ZIP
Phone Number ( )
Name of previous employer
Address
City, State, ZIP
Phone Number ( )
Name of previous employer
Address
City, State, ZIP
Phone Number ( )
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
Job Title/Responsibilities
Was your position Full time Part time
Reason for leaving Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position Full time Part time
Reason for leaving Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position Full time Part time
Reason for leaving Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position Full time Part time
Reason for leaving Terminated Voluntary Involuntary
Explain
Form 8850
(Rev. January 2012)
Department of the Treasury
Internal Revenue Service
Pre-Screening Notice and Certification Request for
the Work Opportunity Credit
a
See separate instructions.
OMB No. 1545-1500
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your name
Social security number
a
Street address where you live
City or town, state, and ZIP code
County Telephone number
If you are under age 40, enter your date of birth (month, day, year)
1
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency
for the work opportunity credit.
2
Check here if any of the following statements apply to you.
• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9
months during the past 18 months.
• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food
stamps) for at least a 3-month period during the past 15 months.
• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work
program, or the Department of Veterans Affairs.
• I am at least age 18 but not age 40 or older and I am a member of a family that:
a Received SNAP benefits (food stamps) for the past 6 months, or
b
Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
• During the past year, I was convicted of a felony or released from prison for a felony.
• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the
past year.
3
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past
year.
4
Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or
released from active duty in the U.S. Armed Forces during the past year.
5
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a
period or periods totaling at least 6 months during the past year.
6
Check here if you are a member of a family that:
• Received TANF payments for at least the past 18 months, or
• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning
after August 5, 1997, ended during the past 2 years, or
• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time
those payments could be made.
Signature—All Applicants Must Sign
Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true,
correct, and complete.
Job applicant’s signature
a
Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Cat. No. 22851L
Form 8850 (Rev. 1-2012)
Form 8850 (Rev. 1-2012)
Page 2
For Employer’s Use Only
Employer’s name Telephone no. EIN
a
Street address
City or town, state, and ZIP code
Person to contact, if different from above Telephone no.
Street address
City or town, state, and ZIP code
If, based on the individual’s age and home address, he or she is a member of group 4 or 6 (as described under Members of
Targeted Groups in the separate instructions), enter that group number (4 or 6) . . . . . . . . . . . . . .
a
Date applicant:
Gave
information
Was
offered job
Was
hired
Started
job
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the
information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I
believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
Employer’s signature
a
Title Date
Privacy Act and
Paperwork Reduction
Act Notice
Section references are to the Internal
Revenue Code.
Section 51(d)(13) permits a prospective
employer to request the applicant to
complete this form and give it to the
prospective employer. The information
will be used by the employer to
complete the employer’s federal tax
return. Completion of this form is
voluntary and may assist members of
targeted groups in securing employment.
Routine uses of this form include giving
it to the state workforce agency (SWA),
which will contact appropriate sources
to confirm that the applicant is a
member of a targeted group. This form
may also be given to the Internal
Revenue Service for administration of
the Internal Revenue laws, to the
Department of Justice for civil and
criminal litigation, to the Department of
Labor for oversight of the certifications
performed by the SWA, and to cities,
states, and the District of Columbia for
use in administering their tax laws. We
may also disclose this information to
other countries under a tax treaty, to
federal and state agencies to enforce
federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records
relating to a form or its instructions must
be retained as long as their contents
may become material in the
administration of any Internal Revenue
law. Generally, tax returns and return
information are confidential, as required
by section 6103.
The time needed to complete and file
this form will vary depending on
individual circumstances. The estimated
average time is:
Recordkeeping . . 6 hr., 27 min.
Learning about the law
or the form . . . . . . . 30 min.
Preparing and sending this form
to the SWA . . . . . . . 37 min.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making this form
simpler, we would be happy to hear from
you. You can write to the Internal
Revenue Service, Tax Products
Coordinating Committee,
SE:W:CAR:MP:T:M:S, 1111 Constitution
Ave. NW, IR-6526, Washington, DC
20224.
Do not send this form to this address.
Instead, see When and Where To File in
the separate instructions.
Form 8850 (Rev. 1-2012)
Phil Ownbey c/o First Advantage (888) 570-4455
9800 Crosspoint Boulevard, Suite 300
Indianapolis, IN 46256
