PERSONAL INFORMATION

Last Name: First Name: Middle Initial:

Address: Apt. #:

City:

State: IL WI IN MI Other

Zip Code:

Home - Area Code: Phone:

Cell - Area Code: Phone:

E-mail Address:

EMPLOYMENT DESIRED

Position Applying For: choose one manager cashier mover & shaker other Date You Can Start Work:

Store Location(s) Where You Would Like To Work (you may list more than one location):

Type Of Seasonal Employment Desired: choose one full time part time anything available

EMPLOYMENT ELIGIBILITY

If you are under 18 years of age, and we require a work permit, can you furnish one? choose one yes no over 18

If no, please explain:

Have you ever work for this company before? choose one yes no

If yes, when & where?

Are you currently employed? choose one yes no

If so, may we contact your current employer? choose one yes no

Are you prevented from lawfully becoming employed in this country due to visa or immigration status? choose one yes no

If hired, the position would require for you to be able to lift over 20 lbs., have no problem working in an outside setting, be on your feet for most of your shift, and have constant contact with various types of plants. Is there any physical condition that would prevent or hinder your ability to perform the above mentioned tasks? choose one yes no

If yes, please explain:

EDUCATION

School #1: Years attended- from: to:

Did you graduate? choose one yes no

Degree or certification(s) Acquired:

School #2: Years attended- from: to:

Did you graduate? choose one yes no

Degree or certification(s) Acquired:

School #3: Years attended- from: to:

Did you graduate? choose one yes no

Degree or certification(s) Acquired:

BRIEF DESCRIPTION OF YOUR SPECIAL SKILLS & QUALIFICATIONS FOR EMPLOYMENT

EMPLOYMENT HISTORY

Job # 1 (most recent)

Name of Employer & address:

Title/Responsibilities:

From: To:

Reason For Leaving:

Job # 2

Name of Employer & address:

Title/Responsibilities:

From: To:

Reason For Leaving:

Job # 3

Name of Employer & address:

Title/Responsibilities:

From: To:

Reason For Leaving:

REFERENCES

#1 - Name: Relationship:

Years Known:

Address & Phone Number:

#2 - Name: Relationship:

Years Known:

Address & Phone Number:

#3 - Name: Relationship:

Years Known:

Address & Phone Number:

AUTHORIZATION

By pressing the submit button below, I certify that my answers are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal, or otherwise, and release the company from all liability for any damage that may result from utilization of such information. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

An Equal Opportunity Employer