Fillable Printable Dissmore's IGA Application for Employment Form
Fillable Printable Dissmore's IGA Application for Employment Form
Dissmore's IGA Application for Employment Form
Dissmore’s IGA Application for Employment
Qualified applicants receive consideration for employment without discrimination based on sex, marital status, race, color, creed, national
origin, age, or presence of a non-job-related handicap. Conditions of employment are stated at the end of this form. Please read carefully
before you sign this application. Any false statements on this application form shall be considered sufficient cause for termination.
Name: ____________________________________________________
Date: _____________________________________
Phone Home: ( ) ___________ – _________________ Cell: ( ) ___________ – _________________
Are you seeking FULL TIME or PART TIME (please circle one)?
FULL TIME
PART TIME
Maximum hours desired: __________
Minimum hours you would accept: __________
What is the length of time you would like to be employed with Dissmores? ___________________________________
What shifts are you currently available for (please circle all that apply)?
Day: 5:00 am – 6:00 pm
Swing: 4:00 – 12:00 am
Graveyard: 12:00 am – 8:00 am
What is your exact time of availability (please write the time you are available to work)?
MONDAY ___________________________________
TUESDAY ___________________________________
WEDNESDAY ___________________________________
THURSDAY ___________________________________
FRIDAY ___________________________________
SATURDAY ___________________________________
SUNDAY ___________________________________
Are you willing to work during Holiday seasons (please circle one)?
YES
NO
If no, why? _________________________________________________________________________________________
Are you currently employed elsewhere (please circle one)?
YES
If yes, where: _________________________________________________________________
Can we call (provide phone number)? ( ) ________________ – _______________
NO
Dissmore’s IGA Application for Employment
Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, creed, national
origin, age, or presence of a non-job-related handicap.
Conditions of employment are stated at the end of this form. Please read carefully before you sign this application. False statements on this
application form shall be considered sufficient cause for termination.
Pick 3 positions (in order of preference, 1 being the job you want the most) in which you are most
interested:
Cashier __________ Freight Stocker __________
Courtesy Clerk __________ Floral Clerk __________
Office __________ Maintenance __________
Espresso Clerk __________ Service Deli __________
Bakery Clerk __________ Grocery Clerk __________
Produce Clerk __________ Meat Clerk __________
Have you attained journey level status in the grocery business (please circle one)?
YES
If yes, what department? _______________________________
How long? _________________________
NO
If any information changes are you willing to inform your interviewer in writing at least ten days prior to
your change in status (please circle one)?
YES
NO
It is understood that, if my application is considered favorable, any false or misleading statement on this
application will be considered sufficient cause for dismissal.
Signed: ____________________________________________________ Date: _________________________________
Dissmore’s IGA Application for Employment
Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, creed, national
origin, age, or presence of a non-job-related handicap.
Please read carefully before you sign this application. False statements on this application form shall be considered sufficient cause for
termination.
PERSONAL (please print)____________________________________________________________________________________________
Name ______________________________________________________ Date ________________________________________
Address ______________________________________________________
______________________________________________________
City State Zip
Job Applied For ______________________________________________________
Salary Expected ______________________________________________________
Names of relatives employed by this company: ______________________________________________________
Have you ever been employed here (please circle one)?
Yes
If yes, please provide the dates: ______________________________________________________
No
Other names under which your employment record may be verified: __________________________________________
Have you ever been convicted of a felony in the past seven years (please circle one)? A conviction is not
an automatic bar to employment consideration.
Yes
No
Are you a U.S. Citizen, or have a Visa permitting work in the U.S. (please circle one)?
Yes
No
Are you 18 or older (please circle one)? Are you 21 or older (please circle one)?
Yes Yes
No No
Have you obtained a high school diploma or GED certificate (please circle one)?
Yes
No
Dissmore’s IGA Application for Employment
Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, creed, national
origin, age, or presence of a non-job-related handicap.
Please read carefully before you sign this application. False statements on this application form shall be considered sufficient cause for
termination.
Education/Training
Include Technical/Academic Achievements/Courses
School
Name/Location
Subject of Specialization
Diploma/Degree
Received
College/University
Specialized
Courses/Training
References
Give the names of three persons not related to you
Name
Address
Telephone
Business
( ) -
( ) -
( ) -
