Application for Employment

General Instructions:

Your Application will not be considered unless all areas are complete and accurate.
We require your date of birth, social security number and drivers license number for background investigation.
All information submitted is subject to verification.

Location Applied For:

Select one Perry Store Shady Grove Store

Position Applied For:

Full Name:

Social Security #:

XXX-XX-XXXX

Date of Birth:

Drivers License #:

XXXX-XXX-XX-XXX-X

Address:

Home Phone:

Cell Phone:

Check the following as it applies to you:

Type of Work:

Choose more than one by holding down “shift” or “ctrl”FullPartTemp

Days:

Choose more than one by holding down “shift or “ctrl”MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Hours Available:

Term Intended
(how long will you stay with the company)

Select one3 – 6 Months6 months – 1 + Year2 – 3 Years3 + Years

Please answer the following questions.

Are you a tobacco user?

Select oneYesNo

Would you be using any type of tobacco products while at work?

Select oneYesNo

Have you ever been convicted of a felony or misdemeanor?

Select oneYesNo

If Yes, please explain in detail:

Will you provide great customer service?

Select oneYesNo

Are you currently employed?

Select oneYesNo

Our retail positions require prolonged walking and/or standing continuously. They also require that employees assist with merchandise stocking and replenishing which requires frequent bending, stooping, crouching, reaching, balancing, pushing/pulling and lifting products/material weighing 40 lbs or more. Are you able to satisfy this job requirement?

Select oneYesNo

Have you been fired or asked to resign?

Select oneYesNo

If Yes, please explain in detail:

What date are you available to begin work, If hired?:

Please list 2 current or previous co-workers and their phone numbers:

EDUCATION:

High School:
Name/Location of School:

Diploma:
Other:
None:

College/Trade School/Etc.:
Name/Location of School:

Diploma:
Other:
None:

Work Experience

***Begin with most recent***

Work 1Company Name:

Supervisor:

Address:

Phone Number:

Job Title:

Job Description:

Reason for Leaving:

Starting Salary:	Ending Salary:
Start Date:	End Date:

Work 2Company Name:

Supervisor:

Address:

Phone Number:

Job Title:

Job Description:

Reason for Leaving:

Starting Salary:	Ending Salary:
Start Date:	End Date:

Work 3Company Name:

Supervisor:

Address:

Phone Number:

Job Title:

Job Description:

Reason for Leaving:

Starting Salary:	Ending Salary:
Start Date:	End Date:

Work 4Company Name:

Supervisor:

Address:

Phone Number:

Job Title:

Job Description:

Reason for Leaving:

Starting Salary:	Ending Salary:
Start Date:	End Date:

References

***Do not list Relatives or Friends***

Name:Address:

Telephone:

Relationship:

Name:Address:

Telephone:

Relationship:

Name:Address:

Telephone:

Relationship:

Name:Address:

Telephone:

Relationship:

Application Certification:I certify that this entire application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I understand falsification or misstatements of this information are grounds for refusal to hire or, if hired, dismissal.I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability from any damage that may result from furnishing such information to you. I acknowledge my employment is at will and I further acknowledge that my employment may be terminated and any offer of employment, if such is made, may be withdrawn with or without cause, and with or without prior notice, at any time, at the option of my employer or myself.


Applicants Signature:	Date:

Background Investigation Disclosure and Authorization:This is to notify you that in connection with your application for employment or during the course of you employment, we may procure a consumer report on you as part of the process of considering your application and/or evaluating your suitability for employment, promotion, reassignment or retention as an employee. Such a report, if obtained, will be prepared by a consumer reporting agency. The types of reports that may be requested, include, but are not limited to, credit reports, criminal record reports, motor vehicle records, court record reports, and/or summaries of educational and employment records and histories.

Please be advised that we may also obtain an investigative consumer report including information as to your character, general reputation, personal characteristics, and mode of living. This information may be obtained by contacting your present and previous employers or references supplied by you.

If we intend to make or do make an adverse decision with regard to your application or employment (if any) based entirely or in part on the information contained in a consumer report, you will be notified as required by applicable state and/or federal law. In addition, law requires your consent before we may obtain a consumer report or investigative consumer report pertaining to your potential employment or actual employment.

By signing below, you grant ROCKY’S the authority to conduct any background investigations, including, but not limited to, credit reports, criminal record reports, court record reports, motor vehicle reports, and/or summaries of educational and employment records and histories, either in connection with your job application, or in connection with any future decisions concerning your employment, promotion, reassignment or retention as an employee of ROCKY’S. You further grant ROCKY’S the authority to verify all information you have provided to ROCKY’S. You also authorize all entities having information about you, including present and former employers, criminal justice agencies, departments of motor vehicles, school and credit reporting agencies, to release such information to ROCKY’S or to any firm retained by ROCKY’S to conduct employee investigations.

This release and authorization shall remain valid and in effect during the term of your employment. We reserve the right to run subsequent consumer reports and /or investigative consumer reports on an as-needed basis. A photocopy of facsimile of this Notice and Authorization form shall be considered as effective and valid as the original.


Applicants Signature:	Date:

Drug Test Consent:As a prospective employee of ROCKY’S (“the Company”), understand that the use of drugs, alcohol and other controlled substances by employees creates a dangerous work environment. In consideration for my desire for a safe work environment, I hereby give my consent for the Company to conduct the drug tests it considers necessary as outlined in its Drug Test policy. I understand that this drug test is a condition for employment. I hereby allow the Company to take the specimens from me to test for any controlled substances, and I authorize the laboratory or medical personnel retained by the Company for these tests to release the results to the Company for whatever use the Company deems appropriate. Further, I release the laboratory or medical personnel conducting the drug test, the Company, and the Company’s employees, directors, officers and successors from any liabilities, claims and caused of action, known or unknown, contingent or fixed, that may result from this drug test. I agree not to file any lawsuit or other action to assert a claim.

I have read and understood the agreement, and I sign this without any coercion or duress by any individual or institution.


Applicants Signature:	Date: