Fillable Printable Safeway Application Form
Fillable Printable Safeway Application Form
Safeway Application Form
1/2008
J O B T I T L E
Safeway Employment Application
C L I E N T
Kristle Baker
G A #
46093
J R #
Co11 40 97
D E S I G N E R
JEB/KC
W E E K #
W E E K LY I N S E R T
P O S ’ n #
D I V I S I O N
Corporate
V E R / S T O R E #
Non CA Version
P R O O F C Y C L E
11A
O P T I O N
P R O O F D AT E
1/8/08
S I Z E
8.5” X 11”
AN EQUAL OPPORTUNITY EMPLOYER
The Safeway policy is to provide employment, training, compensation, promotion and other conditions of employment without regard to race, color,
religion, sexual orientation, national origin, sex, age, disability, veteran or any other legally protected status. Applicants must reapply at least once
every two months to remain under consideration for employment.
PERSONAL INFORMATION
NAME
First LastMiddle Initial
TEL. NO. ( )
OTHER NAMES USED FOR EMPLOYMENT OR EDUCATION (if any)
ADDRESS
Street/Apt. # StateCity CountyZIP
SOCIAL
SECURITY NO.
FOR WHAT POSITION(S) ARE YOU APPLYING?
FULL-TIME PART-TIME EITHER
PREFERRED FACILITY/STORE?
ARE YOU UNDER THE AGE OF 18?
YES NO IF UNDER 18, STATE YOUR AGE
ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES?
YES NO
HAVE YOU WORKED FOR SAFEWAY OR ONE OF ITS AFFILIATED COMPANIES LISTED AT THE TOP OF THIS APPLICATION?
YES NO
WHEN? WHERE?
POSITION HELD? REASON FOR LEAVING?
LIST THE NAMES OF RELATIVES EMPLOYED BY ANY OF THE SAFEWAY COMPANIES AND THEIR WORK LOCATION
NONE
DATE AVAILABLE FOR WORK TOTAL HOURS AVAILABLE PER WEEK
(Y
ou may list time needed for religious practices/observances as “available” time.) The majority of retail store shifts are afternoons, evenings and weekends.
SUN MON TUES WED THURS FRI SAT
Earliest Time
Latest Time
NAME
RELATIONSHIP WORK LOCATION
1.)
2.)
3.)
YES NO
FOR APPLICANTS OUTSIDE OF HAWAII:
HAVE YOU BEEN CONVICTED OF A CRIME WITHIN THE LAST TEN (10) YEARS (other than a minor traffic violation)?
Hawaii applicants do NOT answer this question.
IF YES, STATE THE DATE, LOCATION, NATURE AND DISPOSITION OF THE OFFENSE:
(A “Yes” answer will not necessarily disqualify you from employment.)
*FOR HAWAII APPLICANTS:
If you are made a conditional offer of employment, you will be asked to provide information regarding criminal convictions prior to hiring.
To learn more & join the Safeway team visit Safeway.com
APPLICATION FOR EMPLOYMENT
(Non-California Applicants ONLY)
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1/2008
J O B T I T L E
Safeway Employment Application
C L I E N T
Kristle Baker
G A #
46093
J R #
Co 11 40 97
D E S I G N E R
JEB/KC
W E E K #
W E E K LY I N S E R T
P O S ’ n #
D I V I S I O N
Corporate
V E R / S T O R E #
Non CA Version
P R O O F C Y C L E
11A
O P T I O N
P R O O F D AT E
1/8/08
S I Z E
8.5” X 11”
EDUCATION
NAME & ADDRESS OF SCHOOLS ATTENDED
FROM
mo/yr
TO
mo/yr
CIRCLE HIGHEST
GRADE/LEVEL COMPLETED
DEGREE/MAJOR
HIGH SCHOOL
COLLEGE
GRADUATE
OTHER
RECORD OF U.S.A. MILITARY AND RESERVE STATUS
Service Dates
FROM mo yr TO mo yr Branch Reserve Unit Meeting Dates
Summarize skills, training or qualifications:
PROFESSIONAL/PERSONAL REFERENCES
NAME ADDRESS PHONE NUMBER OCCUPATION
1.)
2.)
EMPLOYMENT HISTORY
List each job held during the last seven (7) years with a minimum of three (3) employers. Start with your present or last job. Also, include any periods
of unemployment, military service, and volunteer and/or part-time work experience. If necessary, use an additional sheet to include related work
history beyond seven (7) years.
Applicant Signature Date Interviewer’s Signature Date
Certification: I certify that the information I provided on this application is true and correct to the best of my knowledge, and I agree to have this
information checked by the Company. I authorize the references listed to provide the Company with information about my previous employment
and any other information they may have. I release all parties and persons, including the Company, from any and all liability for any damages for
providing this information, consistent with state and federal law.
At-will employment: I understand that nothing in this application is intended to be, or is, an offer of employment or a promise of continued
employment. I understand that if I become employed by the Company, my employment is for no specific term. I further und
erstand that, except
for any periods of time that I am employed in a position covered by an express written agreement that provides otherwise, my employment with
the Company may be terminated at any time, with or without cause and/or notice, at the will of either me or the Company.
I further understand
that no Company representative has any authority to enter into any agreement with me different or contrary to the foregoing.
Eligibility verification: I understand that any false statement or omission on this application may prevent me from receiving an offer of employment,
may result in a withdrawal of an employment offer, or may result in my discharge from employment if I am already employed at the time the false
statement or omission is discovered.
I understand that any offer of employment is conditioned on satisfactory proof of my identity, that I am of legal age, and that I have legal authorization to work
in the United States. I also understand that this may include the Company’s receipt of satisfactory responses to reference requests, my passing of any required drug
screening test, satisfactory completion of a background check, if applicable, and satisfactory completion of a post-offer medi
cal examination, if applicable.
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
ST
ART
FINAL
ST
ART
FINAL
ST
ART
FINAL
ST
ART
FINAL
ST
ART
FINAL
READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE THE APPLICATION
EMPLOYMENT
DATES (mo/yrs)
COMPANY AND
MAILING ADDRESS
SUPERVISOR’S
NAME/PHONE
SALAR
Y YOUR JOB TITLE SPECIFIC JOB DUTIES
REASON FOR
LEAVING
Please initial each of the following paragraphs:
9 10 11 12
1 2 3 4
1 2 3 4
1 2 3 4
To learn more & join the Safeway team visit Safeway.com
APPLICATION FOR EMPLOYMENT
(Non-California Applicants ONLY)
Have you ever been fired from a job or given an opportunity to resign? Yes No
If yes, Explain:
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1/2008
J O B T I T L E
Safeway Employment Application
C L I E N T
Kristle Baker
G A #
46093
J R #
Co 11 40 97
D E S I G N E R
JEB/KC
W E E K #
W E E K LY I N S E R T
P O S ’ n #
D I V I S I O N
Corporate
V E R / S T O R E #
Non CA Version
P R O O F C Y C L E
11A
O P T I O N
P R O O F D AT E
1/8/08
S I Z E
8.5” X 11”
APPLICATION INFORMATION
To be completed by Applicant
NAME (Required)
First LastMiddle Initial
Source Code
Walk-in
Newspaper Advertisement
Employee Referral
Employment Agency
Female/Minority Group Referral
Community/Vocational Rehab Org
High School/College Referral
Job Fair/Recruiting Event
Internal Postings
Job Postings
Other (Explain) _______________
____________________________
Internal Employee Application
TO BE COMPLETED BY HIRING PERSONNEL ONLY
Application Date
Month Day Year
Jan
Feb
Ma
r
Ma
y
Jun
Jul
Au
g
Sep
Oc
t
No
v
Dec
Ap
r
0
1
2
3
0
1
2
3
4
5
6
7
8
9
2005
2006
2007
2008
2009
2010
Race/Ethnic Group
SELECT ONLY ONE
American Indian/Alaskan Native
Native Hawaiian/
Other Pacific Islande
r
Black/African American
Asian
Hispanic/Latino
White
Two or More Races
Decline Disclosure
Gender
Male
Female
Decline Disclosure
Job Group Codes
1B Assistant Store Managers
1C Depar
tment Managers
1D Head Clerks
1E Pharmacy Manager
1F Supply Manager/Supervisor
1G Backstage Manager
1H Distribution Manager
2A Pharmacist
2B Professionals
3A Technician
4A Food Clerks: Jny/App/Produce
4B Ser
vice Departments
4C Courtesy/Helper Clerks
5A Senior Clerical
5B Clerical
6A Crafts, Skilled
7A Operators,
Semi-Skilled
8A Laborers, Unskilled
9A Ser
vice Workers
Disposition Codes
A = No position available within the last 60 days
B = More qualified applicants available
C = Unavailable to work required hours
D = Available type of work was not acceptable
E = Unable to contact/unavailable for interview
F = Wage not acceptable
G = Did not meet post-offer policy requirements
H = Declined job offer
I = Did not show up for interview
J = Ineligible for rehire
K = Did not pass pre-employment test
L = Hired
M = Other
Interview Date
Month Day Year
Jan
Fe
b
Ma
r
Ma
y
Ju
n
Ju
l
Au
g
Se
p
Oc
t
No
v
De
c
Ap
r
0
1
2
3
0
1
2
3
4
5
6
7
8
9
2005
2006
2007
2008
2009
2010
(mark appropriate boxes)
To learn more & join the Safeway team visit Safeway.com
APPLICATION FOR EMPLOYMENT
(Non-California Applicants ONLY)
Race/Ethnic Group
SELECT ONLY ONE
American Indian/Alaskan Native
Native Hawaiian/
Other Pacific Islande
r
Black/African American
Asian
Hispanic/Latino
White
Two or More Races
Decline Disclosure
Gender
Male
Female
Decline Disclosure
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1/2008
J O B T I T L E
Safeway Employment Application
C L I E N T
Kristle Baker
G A #
46093
J R #
Co 11 40 97
D E S I G N E R
JEB/KC
W E E K #
W E E K LY I N S E R T
P O S ’ n #
D I V I S I O N
Corporate
V E R / S T O R E #
Non CA Version
P R O O F C Y C L E
11A
O P T I O N
P R O O F D AT E
1/8/08
S I Z E
8.5” X 11”
NOTICE AND CONSENT CONCERNING CONSUMER REPORTS
AND INVESTIGATIVE CONSUMER REPORTS
This form, which you should read carefully before signing, has been provided to you because Safeway Inc. (“the Company”) may
request consumer reports or investigative consumer reports from USIS Commercial Services, Inc. (“USIS”) in connection with your
application for employment or, if you are or become employed by the Company, during the course of your employment with the
Company. Such reports may be requested for purposes of evaluating your suitability for employment, promotion, reassignment,
retention or other employment-related purposes.
The types of reports that the Company may request from USIS include, but are not limited to: credit reports, criminal records checks,
court records checks, driving records, and/or summaries of educational, employment records and histories, and investigative co
nsumer
reports (reports with information regarding your character, general reputation, personal characteristics or mode of living). The
information contained in these reports may be obtained by USIS from public record sources, educational institutions, USIS clients, or
through personal interviews with your co-workers, neighbors, friends, associates, current or former employers, or other people
you
know. You have the right to request additional disclosures of the nature and scope of the investigation by USIS and a statemen
t of
your rights. To receive this information or to inspect any files concerning such a report or to determine if a report on you
has been
requested, you may contact USIS by mail at 4500 S. 129th East Avenue, Suite 200, Tulsa, Oklahoma 74153, by phone at (800) 331-9175
or by fax at (918) 627-6162.
If any adverse decision with regard to your application for employment with the Company or, if you are hired, during the cours of your
employment, is based in whole or part on the information contained in a consumer report or an investigative consumer report, you
will be notified as to the basis for the decision and given a copy of the report, as well as a summary of your applicable rights.
CONSENT TO CONSUMER REPORTS AND INVESTIGATIVE CONSUMER REPORT
S
I have carefully read and understand the
Notice Concerning Consumer Reports and Investigative Consumer Reports and this Consent
to Consumer Reports and Investigative Consumer Reports
(“Consent”) and, by my signature below, I authorize USIS to release
consumer reports and/or investigative consumer reports, as described above, to the Company: (1) in conjunction with my application
for employment and (2) during the entire course of my employment. I further understand that any and all information contained
in
my job application or otherwise disclosed to the Company by me before or during my employment may be utilized for the purpose
of
obtaining the consumer reports or investigative consumer reports requested by the Company, and I confirm that all such information
provided in connection with my job application is true and correct. I also agree that a facsimile, photocopy or electronic co
py of this
form may be used in lieu of the original.
I also authorize the following entities to disclose to USIS and its agents all information about or concerning me, including,
but not
limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all
other
federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor ve
hicle records
agencies; all other private and public sector repositories of information; and, any other person, organization or agency with
any
information about or concerning me. The information that can be disclosed to USIS and its agents includes, but is not limited to,
information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal his
tory,
drug test results, military service, professional credentials, and all other information requested by USIS or its agents.
NOTICE TO WASHINGTON ST
ATE APPLICANTS OR EMPLOYEES
If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a
right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the righ
t to
ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
NOTICE TO WASHINGTON STATE APPLICANTS OR EMPLOYEES
If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a
right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the righ
t to
ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Name of Applicant (Print)
Applicant or Employee Signature
Date
, 20
Social Security Number
Street Address
City, State and ZIP Code
2
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