Step 1 of 11 9% PRE-EMPLOYMENT QUESTIONNAIREName First Middle Last Mobile PhoneAddress 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 Type of employment desired: full time only part time only What is your hourly requirement?How many days of work have you missed this past year?Please enter a number from 0 to 365.How many days of work have you been late this past year?Please enter a number from 0 to 365.We occasionally require our employees to work on Saturdays. Are you willing to work on Saturdays? yes no Have you ever been discharged or asked to resign your employment? yes no If yes, please give the particularsHave you had any experience in an administrative or office position? yes no Family Fare is a franchisor of convenience stores. Have you had 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 BENEFITSHealth 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 objections to a dress code or certain appearance requirements? yes no To move forward in the application process, you will have to 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 of High SchoolHigh School Location 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 Number of Years Attended High SchoolPlease enter a number from 0 to 10.Did You Graduate High School? yes no Subjects Studied in High School?CollegeName of CollegeCollege Location 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 Number of Years Attended CollegePlease enter a number from 0 to 10.Did You Graduate College? yes no Subjects Studied in College?Trade, Business Or Correspondence SchoolName of SchoolSchool Location 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 Number of Years Attended This SchoolPlease enter a number from 0 to 10.Did You Graduate From This School? yes no Subjects Studied at This School? 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)Untitled Starting MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberStarting Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Ending MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberEnding Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925NameAddress 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 from 1 to 99.Reference 2Reference 2 NameReference 2 PhoneReference 2 Email Reference 2 BusinessReference 2 Years KnownPlease enter a number from 1 to 99.Reference 3Reference 3 NameReference 3 PhoneReference 3 Email Reference 3 BusinessReference 3 Years KnownPlease enter a number from 1 to 99. In Case Of Emergency NotifyEmergency Contact NameEmergency Contact 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 Emergency Contact 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
