Lawrence Brothers Employment Application:
Required fields have an asterisk (*).
Contact Information
*Date: (mm) (dd)(yyyyy)
* Last Name:
* First Name:
Middle Name:
Maiden Name:
* Address:
* City
* State:
*Zip: -

*Home Phone:
Best Time To Call
May we contact you at work?
(Please circle your answer)		     Yes     No  
If Yes, work number:
Best time to call at work:
Alternate Phone:
Social Security Number: - -
Drivers License Number: State
*Date you are available for work: (mm) (dd)(yyyyy)
*E-mail:


Position Information
Date you are available to start working: (mm/dd/yyyy)
   

Are you legally authorized to work in the United States and have documentation verifying that authority? (Please circle your answer)
    Yes     No

Position you are applying for:

Second Preference:

What store are you applying for?


Rate of pay you are expecting?


How were you referred to Lawrence Brothers?
Employee Walk In Other 
If Other Explain:
   

Are you available to work: (Please circle your answer)
 Full Time Part Time Temporary 

Specify days and hours if part time or temporary: (Please circle your answers)
  MO TU WE TH FR SA SU
Hours Available to Work?
   

Do you realize it may be necessary for you to work a schedule based on our staffing needs?
(Please circle your answer)

    Yes     No

Is there any reason why you cannot work overtime, weekends, or holidays?
(Please circle your answer)

    Yes     No

Ideal number of hours you prefer to work
   

What is the maximum number of hours?
   

What is the minimum number of hours?
   

*What is your ideal schedule? (Please circle your answesr)
MO TU WE TH FR SA SU

Hours Available to Work?
   

Could You Open? (Please circle your answer)
     Yes     No

Could You Close? (Please circle your answer)
    Yes     No

Explain any conflicts or special requirements:
   

*Have you ever been employed at Lawrence Brothers/Fiesta Foods, IGA or SaveALot?
(Please circle your answer)
    Yes     No

If yes, please provide store location and date:

Store Location

Date:      

Are you related to anyone working here? (Please circle your answer)
   Yes     No
*List relatives and close friends that work for Lawrence Brothers?
   
In case of emergency, notify:
Name   
Address 
Phone 

In case of emergency, secondary notify:
Name   
Address  
Phone 
     *Have you ever been convicted of a felony crime?  (Please circle your answer)
    Yes     No

If yes, please explain:
   

 
Education
Elementary School :
Elementary School : Name & Location of School
No. of Years Completed:
Graduate
(Please circle your answer) 		    Yes     No
If No Please Explain:
Grade Average:  
Field/Major 
High School :
High School : Name & Location of School
No. of Years Completed:
Graduate
(Please circle your answer) 		    Yes     No
If No Please Explain:
Grade Average:  
Field/Major 
College or University :
College/University: Name & Location of School
No. of Years Completed:
Graduate
(Please circle your answer) 		    Yes     No
If No Please Explain:
Grade Average:  
Field/Major 
Graduate School :
Graduate School: Name & Location of School
No. of Years Completed:
Graduate
(Please circle your answer) 		    Yes     No
If No Please Explain:
Grade Average:  
Field/Major 

Education (continued)
Business, Technical, GED, Other :
Business, Technical, GED or Other: Name & Location of School
No. of Years Completed:

Graduate
(Please circle your answer)

    Yes     No
If No Please Explain:
Grade Average:  
Field/Major 
List other experiences, qualifications, business skills, or technical training you have received. (include machines and speed):

Employment History
Tell us about your last 3 employers, starting with most current.

*Are you still employed by the following employer?
(Please circle your answer)

    Yes     No

*May we contact the following employers?
(Please circle your answer)

    Yes      No
Employer #1
*Employer name:
Address Line 1:
Address Line 2:
City:
State:
Zip: -
Employer Phone:
Dates:  
From (mm/yyyy) To (mm/yyyy)
 
Pay rate starting:  
Pay rate ending:  
*Your ending title:
*Supervisor's name:
Employer #2
*Employer name:
Address Line 1:
Address Line 2:
City:
State:
Zip: -
Employer Phone:
Dates:  
From (mm/yyyy) To (mm/yyyy)
Pay rate starting:  
Pay rate ending:  
*Your ending title:
*Supervisor's name:
Employer #3
*Employer name:
Address Line 1:
Address Line 2:
City:
State:
Zip: -
Employer Phone:
Dates:  
From (mm/yyyy) To (mm/yyyy)
Pay rate starting:  
Pay rate ending:  
*Your ending title:
Comments (including any gaps in employment):
May we contact the employers listed above or on your resume? (Please circle your answer)
   Yes     No
If not - indicate which one(s) you do not wish us to contact:
Personal References
References: List Personal References (Other than relatives or former employers) who know your abilities.
Reference 1:
Name:
Address:
Phone:
Occupation:
Years Known :
Reference 2:
Name:
Address:
Phone:
Occupation:
Years Known :
Reference 3:
Name:
Address:
Phone:
Occupation:
Years Known :
Military Service Record and Reserve Status
U.S. Armed Forces Record: (Please circle your answers)
 
Air Force Army Marines  Navy Coast Guard None
Serial Number:
Rank:
Induction Date:  
(mm) (dd)(yyyyy)
 
Discharge Date:  
(mm) (dd)(yyyyy)
 
Military Reserve Record: (Please circle your answers)
 
Air Force Army Marines  Navy Coast Guard Air Nat. Guard of U.S. Nat. Guard of U.S. None
Current Status: (Please circle your answer)
 
Active Inactive Standby  Retired
Skills Used or Special Training:

I certify that the facts in this application are true and correct to the best of my knowledge, and I understand that my misrepresentation of facts shall be cause for rejection of this application or termination of employment.

I hereby authorize Lawrence Brothers to conduct a work history and personal reference inquiry to determine my acceptability for employment.

I further agree to a pre-employment blood and/or urinalysis test for controlled substances if so requested, and if hired, to submit samples for such test whenever so requested by Lawrence Brothers. I also understand that during my first 90 days of employment, if I test positive for any illegal substance or alcohol, I will be terminated.

If employed, I understand the first 90 days of my employment will be considered an initial employment assessment and that employment my be terminated during this period by either employer and/or employee without prejudice; I understand that my employment is for an infinite period of time; and that employment may be terminated at any time for any reason.

Lawrence Brothers follows the Civil Rights Act of 1964 which prohibits discrimination in employment practice because of race, color, religion, sex, national origin, or disability; PL90-202 which prohibits discrimination because of age, section 504 of the Rehabilitation Act of 1973, as amended, and the American Disabilities Act which prohibits discrimination on the basis of disability.

I hereby represent and warrant that I have read and fully understand the foregoing, and seek employment under these conditions of my own free will and in accordance with my own judgment.

Date(mm) (dd)(yyyyy)



Applicant's Signature