Employment Form

Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

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

Email(Required)

Store Location(Required)

Select store you’re applying to

Position(s) Applying For(Required)

Please Specify(Required)

Date Available To Start(Required)

Varies (Start Date)

Must give two week notice

Desired Wage(Required)

$ Per Hour

What are you interested in working?(Required)

Part Time

Full Time

Temp

Check all that apply

Are you a United States Citizen?

Yes

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

Yes

Have you ever worked for this company?

Yes

If so, when?(Required)

Have you ever been convicted of a felony(Required)

Yes

Please Describe(Required)

Are you over the age of 18?

Yes

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

Yes

Can you perform jobs that require you to lift 25 pounds?(Required)

Yes

Please describe restrictions(Required)

Do you have a valid drivers license?(Required)

Yes

Can you get to work in most weather conditions?(Required)

Yes

Can you get to work without relying on others?(Required)

Yes

Please describe how you plan on getting to work?(Required)

Availability

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

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Education

High School

State

From

Did you graduate?

Yes

College

State

From

Did you graduate?

Yes

Degree

Other

State

From

Did you graduate?

Yes

Degree

References

Do you know anyone that works / worked for White Haven Market, Plymouth Hometown Market, Valley Hometown Market?(Required)

Yes

Please tell us who(Required)

Personal References

Other than relatives and previous employers

Name

First Last

Relationship to you

Place of employment

Phone

Name

First Last

Relationship to you

Place of employment

Phone

Employment History

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

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/DD/YYYY

End Date

MM/DD/YYYY

Reason For Leaving

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/DD/YYYY

End Date

MM/DD/YYYY

Reason For Leaving

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/DD/YYYY

End Date

MM/DD/YYYY

Reason For Leaving

Disclaimer and Signature

I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I understand that any misrepresentation, making false statements, or omission of facts presented on this application may result in rejection of my application or, if employed, in the termination of my employment.
I authorize the investigation of all information contained herein and consent to a thorough background check. I authorize all employers, schools and references to give White Haven Market, Inc. any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I release White Haven Market, Inc. and it’s employees, former employers, schools, and references from all liability for any damage that may result from utilization of such information.
I understand and agree that no representative of White Haven Market, Inc. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by the Store Manager.
I understand that proof of United States citizenship or documentation of the ability to work in the U.S. must be provided at the time of hire. I also understand that I may be asked to submit to routine drug screening.

Signature (type name)(Required)

Date(Required)

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