A Career At Roxy's

About the role

This is an employment application form for a store position. The company is an equal opportunity employer that will make reasonable accommodation in the application process, if needed.

Personal Information

• Full name (First, Middle, Last)
• Street address, City, State, ZIP code
• Primary and secondary phone numbers
• Email address

Work Preference

• Date available to start
• Salary or pay expected
• List job benefits (other than wages) in order of importance
• Prior experience in the kind of work desired
• Job-related formal schooling or training
• Job-related licenses or certificates
• Job-related special skills (typing, machine operation, etc.)

Availability

• Work preference: Full-time, Part-time, Temporary/Short Term, or Long-term
• Shift preference: Day, Afternoon, Night, or Rotating
• Willingness to work daily overtime on occasion if necessary
• Willingness to work extra days in the week if necessary

Present Employment

• Whether advance notice must be given to present employer

Personal

• Willingness to consent to background check or reasonable suspicion drug testing (where not prohibited by law)
• Whether more than a day or two of work or school has been missed in the past five years
• Whether applicant is a minor (under 18 years old)

Prior Events

• Whether applicant has worked for or applied for work at this company before
• Whether applicant has been discharged for cause
• Whether applicant has been convicted of a criminal offense (with explanation space provided)

Education and Training

• Grade and High School: Name, Location, Graduation status, Grade Point Average, Special Courses, highest grade completed (6th through 12th)
• College/University: Name, Location, Years Attended, Major Subject, Degree Attained, Grade Point Average
• Other (Graduate, Trade School, Correspondence School, etc.): Name, Location, Length of Course, Major Subject, Course completion status, Grade Point Average

Record of Employment

• Current/Most Recent Employer: Name, Address, City, State, Phone Number, Start Date
• Whether still employed, and if not, Employment End Date
• Starting Rate of Pay, Ending Rate of Pay
• Reason for Leaving
• Supervisor's Name and Title
• List of jobs held, duties performed, skills used or learned, advancements or promotions
• Whether the company may contact this employer for a reference

Certification

• Applicant certifies all information provided is true and correct
• Omissions or misrepresentations may result in rejection or dismissal if employed
• Authorization for former employers and the company to answer questions and release truthful information
• Agreement to hold all persons harmless for giving truthful information
• Understanding this is a preliminary application and not an employment contract
• Understanding any employment is for no definite period of time
• Agreement to comply with all rules of the company as a condition of continued employment
• Acknowledgment that investigations may include residence verification, employment, education, reputation, character, personal characteristics, habits, and interviews with third parties
• Authorization to release information and hold parties harmless
• Authorization for the company to release truthful information to future potential employers

Digital Acknowledgement: Applicant's name and date are required.

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