Brookhaven Marketplace is an equal employment opportunity employer. Our company
will provide reasonable accommodations with the application process upon your request
consistent with applicable laws.
Personal Information
DATE:
Employment Desired
Please list your availability to work:
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Sunday
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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What is the number of maximum hours you can work per
week?
What is the number of hours you prefer to work per
week?
To better serve our customers do you speak any languages
other than English?
EVER APPLIED TO THIS COMPANY
BEFORE?
WHERE?
WHEN?
Education History
Employment Experience
(Please list your employment experience, starting with
the most recent first.)
Are you currently employed?
If yes, may we contact your current employer?
(Brookhaven Marketplace will
only contact current employer only if you consent. Our Company reserves the right
to contact the other employers listed without any further notice to you.)
FROM
MONTH & YEAR
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TO
MONTH & YEAR
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NAME, ADDRESS & PHONE OF EMPLOYER
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SALARY
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POSITION/DUTIES
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REASON FOR LEAVING
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GENERAL INFORMATION
SUBJECT OF SPECIAL STUDY /RESERCH
WORK OR SPECIAL TRAINING/SKILLS
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Military Experience
Position/Supervisor
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REFERENCES
GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED
TO YOU, WHOM YOU HAVEKNOWN AT LEAST ONE YEAR.
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NAME
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ADDRESS
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PHONE NUMBER
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BUSINESS
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Relationship
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PREVIOUS CONVICTION INFORMATION
The existence of a conviction will
not automatically disqualify you as a job applicant. Do not answer “yes” if the conviction has been expunged, annulled,
sealed, statutorily eradicated, pardoned, dismissed upon condition of probation,
or is only a minor traffic violation.
Have you ever been convicted of a crime other than a minor traffic
violation?
If yes, please explain:
AUTHORIZATION
“I
certify that the fact contained in this application are true and complete to the
best of my knowledge and understand that, if employed, falsified statements on this
application shall be grounds for dismissal.
I authorized investigation of all statements
contained herein and the references and employers listed above to give you any and
all information concerning my previous employment and my any pertinent information
they may have, personal or otherwise, and release the company from all liability
for any damage that may result from utilization of such information.
I
also understand and agree that no representative of the company has any authority
to enter into any agreement for employment for any specified period of time, or
to make any agreement contrary to the foregoing, unless it is in writing and signed
by an authorized company representative.
This waiver does not permit the release
or use of disability-related or medical information in a manner prohibited by the
Americans with Disabilities Act (ADA) and other relevant federal and state laws.”
The
application is just that, an application. It is not an offer, promise or contract
of employment, either expressed or implied. All of our employees are “at will” employees,
which means that employees can terminate the employment at any time, for any or
no reason. Brookhaven Marketplace reserves the right to change and/or terminate
an employee’s employment, with or without notice or cause at any time.
DATE:
SIGNATURE: