First Name

Middle Initial

Last Name

Address

City

State

ZIP

Phone Number

Alternate Phone Number

E-mail

Position(s) Desired

Desired Store Location

Will you accept part-time?

Yes No

Are you 18 or older?

Yes No

If no, give birth date:

What specific days and/or hours are you available to work? (Select the checkbox or type in your available hours per day)

I can work any time.

What specific days and/or hours are you not available to work?

Are there restrictions due to:

Another job?
School?
Personal?

Were you previously employed by Community Supermarket?

Yes No

If yes, at which location?