Exxpress Mart

Store:

Position Desired:

Salary Desired:

Date of Birth:

Social Security Number:

Name (Last):

(First):

(Middle):

Address:

City:

State:

Zip:

Telephone Number:

Email:

Have you ever worked for Tri-Con, Inc.?

Yes No

If so, when?:

How did you learn about us?
Advertisement Friend Walk-In Relative Other:

Please list the names of any relatives or friends employed by Exxpress Mart.

Are you over 18 years of age?

Yes No

If you are under 18 years of age, can you provide proof of eligibility to work?

Yes No

Did you receive a copy of the job descriptiton for the position?

Yes No

Are you physically or otherwise unable to perform the duties of the job for which you are applying?

Yes No

If yes, please describe (answering is voluntary and any answers will be kept confidential).

Are you currently employed?

Yes No

Are you legally authorized to work in the United States?
Proof of identity and work authorization will be required upon employment.

Yes No

On what date would you be available for work?

Availability: Full-time Part-time Shift Work Temporary

Can you travel if a job requires it?

Yes No

Have you ever been convicted or pled guilty or no contest to a felony offense?

Yes No

For purposes of employment with Exxpress Mart, "convictions" include, but are not limited to, sentenced to confinement, paid fine, time served, placed on probation (including deferred adjudication), and court-ordered restitution.

City/State:

Charge:

*Please explain

*Conviction of a felony will not necessarily bar you from employment.

EDUCATION

HIGH SCHOOL:

Name:

City/State:

Did you graduate? Yes No

Degree:

COLLEGE:

Name:

City/State:

Did you graduate? Yes No

Degree/Major:

OTHER:

Name:

City/State:

Did you graduate? Yes No

Degree/Major:

Current Certifications/Licenses Held:

EMPLOYMENT HISTORY

Start with your present or last job. You may also include any activities which you believe demonstrate your qualifications for the position applied. "See Resume" is not acceptable.

CURRENT OR MOST RECENT EMPLOYER:

Name:

Address:

Telephone:

Supervisor:

Position:

Starting Salary:

Ending Salary:

Dates of Employment: to

Reason for leaving:

Duties:

May we contact your current or most recent employer for a reference? Yes No

NEXT PREVIOUS EMPLOYER:

Name:

Address:

Telephone:

Supervisor:

Position:

Starting Salary:

Ending Salary:

Dates of Employment: to

Reason for leaving:

Duties:

May we contact your current or most recent employer for a reference? Yes No

NEXT PREVIOUS EMPLOYER:

Name:

Address:

Telephone:

Supervisor:

Position:

Starting Salary:

Ending Salary:

Dates of Employment: to

Reason for leaving:

Duties:

May we contact your current or most recent employer for a reference? Yes No

Complete the following information only if applying for a position that requires use of a vehicle while conducting company business. If hired, your information will be verified with a Motor Vehicle Report.

How many traffic violations have you had during the last two years?
Driver's License Number: State:

REFERENCES

Name only those persons who are familiar with your work capabilities. Do not list relatives.

Name:

Phone:

Company:

Relationship:

Position:

Years Known:

Name:

Phone:

Company:

Relationship:

Position:

Years Known:

Name:

Phone:

Company:

Relationship:

Position:

Years Known:

What is 3 + 3 = ?

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I understand that I may be required to successfully complete a pre-employment physical examination conducted by a company-authorized physician and that I may be required to successfully pass a pre-employment drug/alcohol screening after I accept a conditional offer of employment.