Fillable Printable RadioShack Application Form
Fillable Printable RadioShack Application Form
RadioShack Application Form
What dates? From
To
Where?
$ hr / wk / annual
Were you previously employed by RadioShack Corporation (formerly Tandy Corporation) or one of its subsidiaries?
If yes:
Yes
No
What position?
What division or subsidiary?
If not, have you previously applied at any RadioShack (or Tandy) location?
If yes:
Yes
No
Date?
Location?
Division or subsidiary?
Have you been convicted of a felony in the past 7 years? (Applicants seeking employment in Hawaii do not answer yes or no, please choose Not
Applicable - Hawaii) (Responding yes to this preliminary question does not necessarily preclude you from being considered for employment. However,
eligibility for employment will be based upon the information contained in your criminal report to the extent allowed by law.)
We Are Proud To Be A Drug-Free Workplace
APPLICATION FOR AT-WILL EMPLOYMENT
FOR COMPANY USE
Unit Applied at: Starting Date: Job Title:
Unit Hired at: Starting Rate: Social Security Number: Job Code:
PLEASE COMPLETE FULLY — PRINT CLEARLY. READ DISCLOSURE STATEMENTS ON PAGE 3 BEFORE COMPLETING APPLICATION.
Name of person where message can be left:
Are you under 18 years of age?
Yes No
( )
EMPLOYMENT INTEREST
Full Time
Part Time
Seasonal/Temporary
Earnings Required: Available to Start:Position Applying For:
Hours
Available
Each Day
A.M.
P. M .
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Total Hours
Per Week
050-3006 Rev. 7/05
EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Name
Address
Last First Middle
City State Zip Code
( )
Home Phone Number
If yes, describe in detail:
Yes No
Office Phone Number
( )
Message Phone Number
Are you authorized to work in the United States?
Yes No
Number Street Apt #
( )
Cellular Phone Number
Please indicate any other names under which you have worked:
Not Applicable - Hawaii
2
EMPLOYMENT HISTORY
Starting with the PRESENT or MOST RECENT, list all previous employers. Include self-employment, military service, summer and part-time jobs. If you need more space,
continue on a separate sheet.
Address
City, State, Zip
Phone No.
BUSINESS REFERENCES
Name and Title
Name and Title
Company
Company
Phone Number
Phone Number
( )
( )
Name and Title
Company
Phone Number
( )
Mo. Yr.
Mo. Yr.
From
Type of Business
Name of Company
Explain Periods Between Jobs:
Describe Your Position and Duties
Starting Salary
Reason for Leaving
Name and Title of
Immediate Supervisor
To
May We Contact
Yes
No
1 EMPLOYER
Address
City, State, Zip
Phone No.
Mo. Yr.
Mo. Yr.
From
Type of Business
Name of Company
Explain Periods Between Jobs:
Describe Your Position and Duties
Starting Salary
Reason for Leaving
Name and Title of
Immediate Supervisor
To
May We Contact
Yes
No
Address
City, State, Zip
Phone No.
Mo. Yr.
Mo. Yr.
From
Type of Business
Name of Company
Explain Periods Between Jobs:
Describe Your Position and Duties
Starting Salary
Reason for Leaving
Name and Title of
Immediate Supervisor
To
May We Contact
Yes
No
Address
City, State, Zip
Phone No.
Mo. Yr.
Mo. Yr.
From
Type of Business
Name of Company
Explain Periods Between Jobs:
Describe Your Position and Duties
Starting Salary
Reason for Leaving
Name and Title of
Immediate Supervisor
To
May We Contact
Yes
No
2 EMPLOYER
3 EMPLOYER
4 EMPLOYER
For the past 7 years including salary/wage history
Ending Salary
Ending Salary
Ending Salary
Ending Salary
• I certify that the information contained in this application is true and correct to the best of my knowledge and understand
that any false statement or omission on this application is grounds for rejection of my application or, if discovered after I am
employed, termination.
• I consent and authorize RadioShack Corporation to conduct an investigation, including but not limited to, verification of employ-
ment-related information. I understand that further information concerning the nature and scope of such investigation, if one
is made, is available to me upon request. I hereby authorize all previous employers to release any information they may have
concerning me, excluding medical information, and I release all such employers for any and all liability arising out of the
release of such information to RadioShack Corporation. I understand that the information provided in this application will be
used solely for determining my eligibility for employment.
• In accordance with RadioShack Corporation’s drug-free workplace policy, applicants being considered for employment
in designated positions or within designated markets must satisfactorily pass a urine test conducted at a local medical
facility for the purpose of determining the presence of illegal drugs. I understand if I am selected for consideration of
employment in a designated position or market, I will be provided complete details regarding the testing procedures and have
an opportunity to execute authorization and consent forms prior to any testing.
• I understand and agree that if an offer of employment is made, I must provide documentation evidencing my authorization to
work in the United States, in accordance with the Immigration Reform and Control Act of 1986, as amended.
• I understand and agree that if employed, I will be an employee at will. As an employee at will: (1) either RadioShack
Corporation or I may terminate the employment relationship at any time, with or without cause; and (2) there is no agreement,
express or implied, between RadioShack Corporation and me for any specific period of employment or for continuing or long-
term employment. I understand and agree that if hired my at will employment with RadioShack Corporation may only be
modified by a separate written document signed by me and an executive officer of RadioShack Corporation.
CERTIFICATION AND AGREEMENT
Please read carefully before signing.
SPECIAL SKILLS
Years
Attended
EDUCATION AND TRAINING
Graduated? Degree or Diploma
High School (Name, City, State)
College (Name, City, State)
Post Graduate (Name, City, State)
Business or Trade (Name, City, State)
________
to
________
________
to
________
________
to
________
Yes No
Yes
No
Mo. / Yr. ______
Yes
No
Mo. / Yr. ______
Yes
No
Mo. / Yr. ______
3
Software Knowledge:
List any special training, skills, hobbies, or interests you believe help qualify you for the position applied for:
Signed
APPLICANT SIGNATURE
Date
FOR INTERVIEWER’S USE
(TO BE COMPLETED FOR ALL APPLICANTS)
DATE
EVALUATION COMMENTS
NAME OF
INTERVIEWER
EMPLOYMENT VERIFICATION AND REFERENCE INFORMATION
EMPLOYER
DATES OF EMPLOYMENT JOB TITLE REASON FOR LEAVING
1
2
3
ADDITIONAL
NUMBER
ADDITIONAL
NUMBER
SKILLS PROFICIENCY RESULTS
SKILL ASSESSMENTS
DATE
RAW
SCORE
NET
SCORE
SKILL ASSESSMENTS
DATE
RAW
SCORE
NET
SCORE
Applicant – Do Not Write on This Page
WORK OPPORTUNITY TAX CREDIT/
WELFARE TO WORK
FOR USE WITH
8850
TO APPLICANT:
We need your help! In 1996 Congress passed legislation that gave employers a
credit against their federal income tax liability for hiring certain employees. This
credit, named the Work Opportunity Tax Credit, was established to increase
employment opportunities for specific target groups. Some of these groups include
individuals who have participated in state rehabilitation programs, or people
involved in government assistance programs such as food stamps. For more
information, please refer to the “Privacy Act and Paperwork Reductions Act
Notice” on the back of the Form 8850.
We request that all prospective employees complete and sign the Form 8850 and
the Survey/Release Form. The purpose of this form is to identify and verify tax
credits for this company and is not intended to determine your work eligibility.
TO EMPLOYER: Before mailing to TALX please check the following:
Applicant signed and dated the 8850 Form.
Applicant signed and dated the Survey/Release Form.
Attach a copy of the applicant’s Driver’s License or State I.D.
Follow usual procedures for reporting new hires to TALX.
If you have any questions call TALX at 1-800-527-8582.
TALX
P.O. BOX 802233
Dallas, TX 75380-2233
Rev. 6-9-06
Company______________________________________________ Branch or Location Number_____________________
Name Social Security Number
Current Address City & State ZIP Code
Position Applying For
Have You Ever Worked For
This Company Before? _________
1. I am a member of a family that received AFDC or TANF:
YES NO NOT SURE
(AFDC = Aid to Families with Dependent Children / TANF = Temporary Assistance for Needy Families)
a. for at least 9 months within the last 18 months
____ ____ ____
b. for the last 18 months in a row
____ ____ ____
c. for any 18 months after August 5, 1997
____ ____ ____
d. stopped receiving within the last 2 years because the benefits ran out.
____ ____ ____
2. I have received Supplemental Security Income (SSI) for at least
1 month within the last 3 months.
____ ____ ____
3. I am a member of a family that received Food Stamps:
a. the last 6 months
____ ____ ____
b. 3 out of the last 5 months & no longer eligible to receive it.
____ ____ ____
4. I am a Military Veteran and a member of a family that received
Food Stamps for at least 3 months within the last 15 months.
____ ____ ____
If You Checked "Yes" or "Not Sure" To Any Question Above, Complete the Information Requested Below and Continue Survey.
County of Benefits City & State of Benefits Primary Recipient (Name & Social Security Number)
Case Worker Name Case Worker Phone Number Case Number
Branch of Military Service Military ID Number Entrance Date
Discharge Date
5. I am currently enrolled in or have completed a State or Veteran sponsored
YES NO NOT SURE
Vocational Rehabilitation Program.
____ ____ ____
If You Checked "Yes" or "Not Sure" To Any Question Above, Complete the Information Requested Below and Continue Survey.
Counselor Name Counselor Phone Number Counselor Address
City, State & ZIP Code (of Program) County of Program Name of Agency
6. I was convicted of or released from prison for a Felony within the last year
YES NO NOT SURE
or I am in a Pre-Release Program.
____ ____ ____
If You Checked "Yes" or "Not Sure" To Any Question Above, Complete the Information Requested Below and Continue Survey.
Parole/Probation Officer Name Parole/Probation Officer Phone Number
Number of Family Living With Your Income For Last 6 Months
You, Including You
Date Convicted Date Released City, State & County of Conviction City, State & County of Release
I hereby authorize that verification of the information above be released to my employer, or TALX, or State Employment Security Agencies (S.E.S.A.), or State Workforce Agencies
(S.W.A.), or a required federal or state agency (such as Social Security Administration for Supplemental Security Income for the dates requested) for the purpose of enabling my
employer to apply for various federal and state tax credits, including the Work Opportunity Tax Credit (WOTC) or Welfare-to-Work Credit. These programs encourage affirmative
action to hire certain categories of employees. Information will be kept confidential in accordance with EEOC guidelines and the Americans with Disabilities Act.
APPLICANT/EMPLOYEE SIGNATURE_____________________________________ DATE_________________
IMPORTANT: DO NOT DETACH FROM 8850. MAIL IN IMMEDIATELY WITH ORIGINAL SIGNATURE.
PLEASE COMPLETE THE FOLLOWING SURVEY AND RELEASE FORM
STATEMENT OF RELEASE
Date of Birth (If Under Age 25)
TALX SURVEY / RELEASE FORM
Rev. 12/05
RETURN ALL FORMS TO:
TALX, P.O. Box 802233, Dallas, TX 75380-2233
OMB No. 1545-1500
Form 8850
Department of the Treasury
Internal Revenue Service
Check here if you r eceived a conditional certification from the state employment security agency (SESA) or a participating
local agency for the work opportunity credit.
1
2
● I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any
9 months during the last 18 months.
Cat. No. 22851L
Pre-Screening Notice and Certification Request for
the Work Opportunity and Welfare-to-Work Cr edits
Form 8850 (Rev. 10-02)
(Rev. October 2002)
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your name
Street address where you live
City or town, state, and ZIP code
a Received food stamps for the last 6 months or
Job applicant’s signature
䊳
If you are under age 25, enter your date of birth (month, day, year)
Social security number
䊳
//
● I am a veteran and a member of a family that received food stamps for at least a 3-month period within the last 15
months.
● I was referred here by a rehabilitation agency approved by the state or the Department of Veterans Affairs.
● I am at least age 18 but not age 25 or older and I am a member of a family that:
● Within the past year, I was convicted of a felony or released from prison for a felony and during the last 6 months I
was a member of a low-income family.
b Received food stamps for at least 3 of the last 5 months, but is no longe r eligible to receive them.
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.
Date
//
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Telephone number
() -
䊳
See separate instructions.
Check here if any of the following statements apply to you.
Welfare-to-Work Credit
Check here if you are a member of a family that:
● Received TANF payments for at least the last 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 within the last 2 years, or
● Stopped being eligible for TANF payments within the last 2 years because Federal or state law limited the maximum
time those payments could be made.
Work Opportunity Credit
● I received supplemental security income (SSI) benefits for any month ending within the last 60 days.
4
Check here if you received a conditional certification from the SESA or a participating local agency for the
welfare-to-work credit.
3
All Applicants
Page 2Form 8850 (Rev. 10-02)
For Employer’s Use Only
Employer’s name
City or town, state, and ZIP code
Date applicant:
Telephone no.
Street address
Under penalties of perjury, I declare that I completed 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 or a long-term family assistance recipient. I hereby request a certification that the individual is a member of a targeted group or a long-term family
assistance recipient.
Gave
information
Was
offered
job
Was
hired
Started
job
Employer’s signature
䊳
//// //
//
//
Title Date
EIN
䊳
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)
䊳
()-
Person to contact, if different from above
City or town, state, and ZIP code
Telephone no.
Street address
()-
Privacy Act and
Paperwork Reduction
Act Notice
Section 51(d)(12) per mits a prospective
employer to request the applicant to
complete this for m and give it to the
prospective employer. The infor mation
will be used by the employer to
complete the employer’s Federal tax
return. Completion of this for m is
voluntary and may assist members of
targeted groups and long-term family
assistance recipients in securing
employment. Routine uses of this for m
include giving it to the state employment
security agency (SESA), which will
contact appropriate sources to confirm
that the applicant is a member of a
targeted group or a long-term family
assistance recipient. This form may also
be given to the Internal Revenue Service
The time needed to complete and file
this for m will vary depending on
individual circumstances. The estimated
average time is:
Recordkeeping
2 hr., 46 min.
Learning about the law
or the form
36 min.
Preparing and sending this form
to the SESA
36 min.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making this for m
simpler, we would be happy to he ar from
you. You can write to the Tax For ms
Committee, Wester n Area Distribution
Center, Rancho Cordova, CA
95743-0001.
Do not send this for m to this address.
Instead, see When and Where To File in
the separate instructions.
Section references are to the Inter nal
Revenue Code.
Form 8850 (Rev. 10-02)
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 perfor med by the
SESA, and to cities, states, and the
District of Columbia for use in
administering their tax laws. In addition,
we may disclose this infor mation to
Federal, state, or local agencies that
investigate or respond to acts or threats
of terrorism or participate in intelligence
or counterintelligence activities
concer ning terrorism.
You are not required to provide the
infor mation requested on a form that is
subject to the Paperwork Reduction Act
unless the for m 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
infor mation are confidential, as required
by section 6103.
