Employment Application Personal Infofull name* First Last name you go by if different than abovedate of birth* MM DD YYYY phone*email* Enter Email Confirm Email address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code are you legally eligible to be employed in the United States?*yesnohave you ever been convicted of a felony or a misdemeanor which resulted in imprisonment?*yesnoplease explain*have you ever applied to this company before?*yesnoplease provide details*do you currently, or have you ever known anyone working at Planet Xchange?*yesnoplease provide their name & your relationship to them.*are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?*yesnoEducationhigh school name*location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State did you graduate?*yesnogedstill attendingContinued Educationcollege or trade schoollocation City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State did you graduate?yesnostill attendingdegree received or soughtSpecial Skillsdo you have any special skills or training that can contribute to your job performance?*yesnoplease describe*are you fluent in any languages other than english?*yesnoplease list*Work Historymost recent or current employercity/statephoneemployed from (start date) Date Format: MM slash DD slash YYYY employed to (end date) Date Format: MM slash DD slash YYYY who is your supervisor?why did you leave, or why are you considering leaving?current hourly wage or wage at departure*if still employed, is your current employer aware of your employment search?yesnoif still employed, may we contact your current employer?yesno2nd most recent employercity/statephoneemployed from (start date) Date Format: MM slash DD slash YYYY employed to (end date) Date Format: MM slash DD slash YYYY hourly wage at departurewhy did you leave?3rd most recent employercity/statephoneemployed from (start date) Date Format: DD slash MM slash YYYY employed to (end date) Date Format: MM slash DD slash YYYY hourly wage at departurewhy did you leave?Current AvailabilityNormal hours of operation are Monday-Saturday 10:00 a.m. - 8:00 p.m. & Sunday 11:00 a.m. - 6:00 p.m. Hours may vary depending upon Holidays, Inclement Weather, or unforeseen acts.Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday*School Year AvailabilityIf you are attending School, what will your availability be once it starts?Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday*Hours Desiredhow many hours weekly are you currently seeking?*10-20 hours weekly20-30 hours weekly30-40 hours weeklyOtherIf attending school, how many hours will you seek once it begins?*10-20 hours weekly20-30 hours weekly30-40 hours weeklyOtherhourly wage expected* Minimum Wage-$9 $9-$10 $10-$11 More than $11 hint: Input lowest wage you will accept for this position. Doing so will not affect your ability to earn more. Wages are determined by experience, and raises are based on performance.AuthorizationThe facts set forth in this application and any supplemental information is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurances to the contrary. I understand that I am required to abide by all the rules and regulations of the company. Signature*By typing your name, you agree that all answers are truthful and accurate to the best of your knowledge. Date* Date Format: MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird Choice
