* indicates required fields.

Personal Information

Name (Last, First, Middle)*:

Date (mm/dd/yyyy)*:

Present Address (Street, City, State, Zip)*:

Permanent Address (Street, City, State, Zip)

Phone Number (Area code, no spaces. Example: 5555555555)*:

Email*:

State Name and Relationship to Any Relatives in Our
Employment

Referred By:

Employment Desired

Position:

Date You Can Start (mm/dd/yyyy):

Salary Desired:

Are You Now Employed?

May We Contact Your Employer?
YesNo

Have You Ever Applied to This Company Before?
YesNo

When?

Former Employers

Please List Any Former Employers (Name, Address, Dates, Salary, Position, and Reason for Leaving)

Former Employer 1

Former Employer 2

Former Employer 3

Former Employer 4

Hours and Availability

How many hours are you looking to work?
0-16 Hours16-20 Hours20-35 Hours25+ Hours

When are you available to work? Please list times and days. (*Opening hours will vary. Please check with the store)

References

Give the names of three persons not related to you, whom you have known at least one year.

Reference 1 (Name, Address, Business, Years Acquainted)

Reference 2 (Name, Address, Business, Years Acquainted)

Reference 3 (Name, Address, Business, Years Acquainted)

In Case of Emergency

Please Notify (Name, Address, Phone):

By submitting this form, I confirms that all the information given on this application form is true and complete. I understand that any falsification or deliberate omissions may disqualify my application or lead to my dismissal. I confirm that I am entitled to work in the United States and can provide original documentation to confirm this. I understand that my employment is subject to references that are satisfactory to DePalma’s.

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