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Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

(###)###-####

Email(Required)

Position(s) Applying For(Required)

(be specific – max 3)

Date Available(Required)

MM slash DD slash YYYY

Desired Salary(Required)

Are you a United States Citizen?

Yes

No

If no, are you authorized to work in the US?(Required)

Yes

No

Have you ever worked for this company?

Yes

No

If so, when?(Required)

Are you over the age of 18?

Yes

No

May we perform a background check on you?(Required)

Yes

No

Availability

List approximate times available next to each day. (ex. Monday: 3pm to 10pm)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Education

High School

Address

Street Address Address Line 2 City State ZIP Code

From

To

Did you graduate?

Yes

No

Degree

College

Address

Street Address Address Line 2 City State ZIP Code

From

To

Did you graduate?

Yes

No

Degree

Other

Address

Street Address Address Line 2 City State ZIP Code

From

To

Did you graduate?

Yes

No

Degree

References

Name

First Last

Relationship

Company

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Relationship

Company

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Relationship

Company

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employment History

Please list all present and past employers. Begin with your most recent.

Present/Last Employer

Phone

Address

Street Address City State ZIP Code

Supervisor

Job Title

Salary

Please enter salary range. Starting and end salary.

Responsibilities

Start Date

MM slash DD slash YYYY

MM/DD/YYYY

End Date

MM slash DD slash YYYY

MM/DD/YYYY

Reason For Leaving

Present/Last Employer

Phone

Address

Street Address City State ZIP Code

Supervisor

Job Title

Salary

Please enter salary range. Starting and end salary.

Responsibilities

Start Date

MM slash DD slash YYYY

MM/DD/YYYY

End Date

MM slash DD slash YYYY

MM/DD/YYYY

Reason For Leaving

Present/Last employer

Phone

Address

Street Address City State ZIP Code

Supervisor

Job Title

Salary

Please enter salary range. Starting and end salary.

Responsibilities

Start Date

MM slash DD slash YYYY

MM/DD/YYYY

End Date

MM slash DD slash YYYY

MM/DD/YYYY

Reason For Leaving

Military Service

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature (type name)(Required)

Date(Required)

MM slash DD slash YYYY

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Our Address

Weiser's Market
680 Furnace Hills Pike
Lititz, PA 17543

Our Phone Number

(717) 626-0271

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Mon-Sat: 7AM - 9PM
Sun: 8AM - 6PM

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