Personal Information First Name MI Last Name Address City State Zip Code Phone Number Email Address Would you work... Part-time Full-time Preference Part-time Full-time Were you previously employed by Stop-N-Go? Yes No Position applying for Rate of pay expected Do you have the right to work in the United States? Yes No Date you can start? Do you have difficulty: Bending or stooping? Yes No Lifting and carrying objects as heavy as 35 lbs? Yes No References Personal Reference Name Phone Day / Evening Day Evening Name of Most Recent Employer Address City State Zip Code Phone Dates of Employment From To Salary Start per Finish per Position or Title Person to whom you reported Type of Business Reason for leaving Name of Next Most Recent Employer Address City State Zip Code Phone Dates of Employment From To Salary Start per Finish per Position or Title Person to whom you reported Type of Business Reason for leaving Describe one accomplishment from your employment background that makes you feel proud Specify what hours on which days and nights when you may not be regularly available for work Rank in 1, 2, 3, order your shift preferences Days 1 2 3 Afternoons/Evenings 1 2 3 Midnights 1 2 3

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