Step 1 of 12 8% Pre-Qualification QuestionnaireName First Middle Last Mobile PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current EmploymentCurrent Position/TitleTenure at Current Position What is your salary requirement?What do you consider to be a reasonable amount of working hours in a week for a retail 'District Manager' type position?Please enter a number from 1 to 168.How do you feel about working on weekends?Have you ever been discharged or asked to resign your employment? Yes No If yes, please give the particulars.Do you have any retail experience? Yes No Do you have experience with Microsoft Word and Excel? Yes No If so, how much? Please rate the importance of the following employee benefits:Health Insurance Not Important Kind of Important Important Very Important Critical Retirement Plan Not Important Kind of Important Important Very Important Critical Vacation/sick Not Important Kind of Important Important Very Important Critical Do you have any objection to a dress code or certain appearance requirements? Yes No Will you agree to a credit and criminal background check, and also a drug test. Do you consent to these requirements? Yes No Will you agree to a Confidentiality Agreement and Non Compete Agreement? Yes No How did you hear about this opportunity? PERSONAL INFORMATIONDate MM slash DD slash YYYY Social Security NumberName: Present Address: , Permanent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneMobile Phone: Email: Are you 18 years old or older? Yes No Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes No EMPLOYMENT DESIREDPositionDate You Can Start MM slash DD slash YYYY Salary RequirementAre You Employed Now? Yes No If So, May We Inquire of Your Present Employer? Yes No Referred By EDUCATIONHighschoolName and Location of SchoolNo. Of Years AttendedPlease enter a number less than or equal to 20.Did You Graduate? Yes No Subjects Studied?CollegeName and Location of SchoolNo. Of Years AttendedPlease enter a number less than or equal to 20.Did You Graduate? Yes No Subjects Studied?Trade, Business Or Correspondence SchoolName and Location of SchoolNo. Of Years AttendedPlease enter a number less than or equal to 20.Did You Graduate? Yes No Subjects Studied? GENERALSubjects Of Special Study Or Research WorkSpecial SkillsActivities: (Civic, Athletic, Etc.)Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color, gender or nation of origin of its members. FORMER EMPLOYERS (List below your last three employers, starting with the last one first)Employers From MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberFrom Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925To MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberTo Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Employer NameEmployer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State SalaryPositionReason For Leaving U,S. Military or Naval ServiceRankPresent Membership in National Guard or ReservesWhich of These Jobs Did You Like Best?What Did You Like Most About This Job?Upload ResumeAccepted file types: pdf, doc, docx, Max. file size: 10 MB. REFERENCES Give the names of three persons not related to you, whom you have known at least one year.Reference 1Reference 1 NameReference 1 PhoneReference 1 Email Reference 1 BusinessReference 1 Years KnownPlease enter a number less than or equal to 99.Reference 2Reference 2 NameReference 2 PhoneReference 2 Email Reference 2 BusinessReference 2 Years KnownPlease enter a number less than or equal to 99.Reference 3Reference 3 NameReference 3 PhoneReference 3 Email Reference 3 BusinessReference 3 Years KnownPlease enter a number less than or equal to 99. In Case Of Emergency NotifyContact NameAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone “I certify that the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and condition of my employment may be changed, with or without cause, and with or without notice, at any time by the company.”Date MM slash DD slash YYYY Signature
