Please write down DAYS and HOURS that you are able to work (INCLUDE AM OR PM)
MON                       TUE                        WED                           THU                         FRI                         SAT                       SUN
Home  Store	
Application for Employment	
Last Name First Name
Complete Middle Name
Social Security Number
Have you ever used another name?           If yes, give other name(s) 
used.        
Present Address:  Street                                City                              State        Zip Code          (Area Code) Phone Number
Who referred you to The Home Store?  (Place a checkmark after one or more)
School:         Advertisement:         State Employment:         Home Store Employee:   
      Job Fair:         Self:         Other:
Are you 16 years of age or older?        Can you speak a foreign language?
        If so, which one(s)?
   For purpose of background verification, please
provide month and day ONLY of your birth.	
MO_________  DAY_______   (No year)
Have you been convicted of any
felonies or misdemeanors?   If yes, explain each occurrence and give dates.  Convictions will not 
disqualify you from the job.	
  
#1  Name                                             Job Title                               Employer                             
         Area Code and Phone NumberHigh School                         City, State, Zip Code                                          Graduate?    
    Grade Point Average
Trade School or College      City, State, Zip Code                                          Graduate?    
   Type of Degree         Major Subject
Circle the highest year completed:                      High School or G
ED                College                      Trade or Technical School
                                                                        
           1    2    3    4                        1   2   3   4        
          1   2   3   4
List:  (1) your skills  (2) computer programs you can operate  (3)
 name of job training classes or skill classes completed
POSITION APPLIED FOR (LIST AT LEAST TWO):
What you want:  FULL TIME_____   PART TIME_____   TEMPORARY/SEASONAL_____   DATE CAN START______________
     1.                                                        2.       
                                             3.
Are you employed now?____________     If yes, may we contact your presen
t employer?____________	
1632  Business Ave.
Careerville, MS 99001	
                    
Street Address, City, State, Zip                        Is this a business or home address?
#2  Name                                             Job Title                               Employer                             
         Area Code and Phone Number
Street Address, City, State, Zip                       Is this a business or home address?
#3  Name                                               Job Title                               Employer                             
        Area Code and Phone Number
Street Address, City, State, Zip                       Is this a business or home address?	
(May be provided at hire.)	
References:  List 3 adults, not relatives, who know of your work ethic (dependable person) or work experience.
Please print clearly in blue or black ink.  Complete all sections of this application.  If you have a r
esume, attach it.

Employer (Business name)                       Start Mo/Yr      End Mo
/Yr      Job Title                        	Ending Wage	        Hours/Week   	
  	
EMPLOYMENT BACKGROUND
LIST PRESENT OR MOST RECENT EMPLOYMENT  FIRST (FOR PAID & UNPAID JOBS	
)
Street Address                                               City              
                      State                    Zip                  (Ar
ea Code) Phone Number
Supervisor’s Name (first and last)             Reason for Leaving (if still employed, print the following in space: Presently employed)
List your duties at this paid or unpaid job 
Street Address                                                City             
                      State                      Zip                 (A
rea Code) Phone Number
Supervisor’s Name (first and last)             Reason for Leaving
List your duties at this paid or unpaid job
Street Address                                            City                                   State         Zip                (Area Code) Phone Number
Supervisor’s Name (first and last)             Reason for Leaving
List your duties at this paid or unpaid job	
PLEASE GIVE CAREFUL CONSIDERATION TO THE STATEMENTS BELOW APPLICANT’S  CERTIFICATION AND AGREEMENT	
Write your initials in the spaces below to verify that you read and under
stand the following statements.
___________ For pre-employment screening, the Home Store may obtain a re
port of my credit history and may review the  following information: Social Security Number, driver history, criminal records, prior employment, and education. 
___________ I certify that this application is accurate and does not con
tain any false or misleading statements of information  requested.  I understand that false or misleading statements constitute 
grounds for termination.
___________ I understand and agree that if the Home Store offers employment to me, this application shall constitute a contract
  of at-will employment such that either I or the Home Store may terminate
 my employment at any time, for any 
reason, with or without cause, with or without prior notice. 
I have read, and I understand and agree to the above certifications, statements, and agreements.
Applicant’s  Signature:_____________________________________________________    Date:___________________________                     	
Bring this sample application when applying for jobs
so your information is ready to transfer to paper or computer applicatio
ns!	
Employer (Business name)                        Start Mo/Yr     End Mo
/Yr      Job Title                                  	 Ending Wage	        Hours/Week
Employer (Business name)                        Start Mo/Yr      End M
o/Yr     Job Title                                   	
 Ending Wage	       Hours/Week	
Your initials
Your initials
Your initials Use dash if no pay
Use dash if no pay
Use dash if no pay