Employment Application Step 1 of 6 16% LUEPTOW’S INC. Frank’s Piggly Wiggly (Elkhorn, East Troy), Frank’s Liquor (Elkhorn) APPLICATION FORM An Equal Opportunity Employer Date Date Format: MM slash DD slash YYYY Personal InformationName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country How long have you lived at this address?(years & months)Telephone NumberCell Phone NumberEmergency Phone Numbere-mail addressPiggly Wiggly Card NumberThe number on the back that starts with 4. AvailabilityWe are open all hours, please indicate am or pm Please enter the hours for each day you are available (i.e. 10am to 6pm)SundayMondayTuesdayWednesdayThursdayFridaySaturdaySundayAble to Work Holidays?(Note: we are closed Christmas Day)YesNoApplying ForFull-TimePart-TimeNumber of Hours DesiredDo you know of any restrictions, personal or otherwise, which would restrict the hours you can work.YesNoIf yes, explain:If hired, do you have reliable transportation to travel to and from work?Date you can begin workKind of work desiredSalary desiredSalaryper hourper weekIf you have done this kind of work before, briefly describe your duties:How did you hear about employment opportunities with us?Where do you grocery shop?Are you at least 18 years of age?YesNoIf not, enter date of birth Date Format: MM slash DD slash YYYY If not, enter ageAre you legally allowed to work in the USA?YesNoHave you ever been convicted of a crime?YesNoIf yes, please explainA criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.Have you previously applied or been interviewed in the last year?YesNo Employment HistoryIMPORTANT: Please list ALL present and previous employment, including part-time and summer employment. Please list in order of last or current employ first. Account for any gaps in your employment. Company NameType of BusinessAddressPhoneStaring EmploymentStarting DateStarting DutiesStarting EarningsLeaving EmploymentLeaving DateLeaving DutiesLeaving EarningsReason for LeavingLast immediate supervisor’s name and titleWould you like to enter another employer?YesNoCompany NameType of BusinessAddressPhoneStaring EmploymentStarting DateStarting DutiesStarting EarningsLeaving EmploymentLeaving DateLeaving DutiesLeaving EarningsReason for LeavingLast immediate supervisor’s name and titleWould you like to enter another employer?YesNoCompany NameType of BusinessAddressPhoneStaring EmploymentStarting DateStarting DutiesStarting EarningsLeaving EmploymentLeaving DateLeaving DutiesLeaving EarningsReason for LeavingLast immediate supervisor’s name and titleMay we contact your present employer?YesNoMay we contact your past employers?YesNo References(Other than relative or former employers.)ReferencesNameAddressPhoneBusiness or Occupation EducationSchool InformationSchool NameAddressCourse of StudyYears CompletedDid you Graduate?Diploma or Degree Received Only clearly job-related education is considered when a hiring decision is made.Special Skills & QualificationsSummarize special skills and qualifications acquired from employment or other experience:Why have you left, or are planning to leave your present job? Form I-9Lueptow’s Inc. is required by Federal Law to submit a complete Form 1-9 for all new employees within THREE days of hire. This form is part of the Immigration Reform & Control Act of 1986 and verifies an individual’s identity and eligibility to work. If hired, you will need to provide us with either one document from List A, or one document from List B and one document from List C. List ADocuments that Establish Identity and Employment Eligibility 1. United States Passport 2. Certificate of United States Citizenship 3. Certificate of Naturalization 4. Unexpired foreign passport with attached Employment Authorization 5. Alien Registration Card with photograph List BDocuments that Establish Identity 1. A State-issued driver’s license or a State-issued ID card with a photograph, or information including name, sex, date of birth, height, weight, and color of eyes. 2. U.S. Military Card 3. Other document establishing identity; i.e., school lD card, sheriff’s ID, work permit List CDocuments that Establish Employment Eligibility 1. Original Social Security Number Card (other than a card stating it is not valid for employment) 2. A birth certificate issued by the State, county, or municipal authority bearing a seal or other certification. 3. Unexpired INS Employment Authorization Specify form. WORK PERMTS We are required to obtain a work permit from all employees under 18 before they may begin work. If you are under 18 and are hired, you will need to obtain a Work Permit Request from us, a letter from a parent or guardian acknowledging the job and requesting the issuance of the work permit, a copy of your birth certificate and a Social Security card. Generally, work permits are issued at the school the minor is attending. Lueptows Inc. will pay the Work Permit fee, if there is one. PRE-EMPLOYMENT STATEMENT (Please read carefully and sign the statement below.) I understand and agree that: The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of employment, or, if employed, termination from employment. I understand that after an offer of employment is made, but prior to starting work, I may be required to undergo and successfully pass a screening for drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of Lueptow’s Inc. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to Lueptow’s Inc. In processing my application for employment, the company may verify all the information provided by me, or may procure or have prepared a consumer or an investigative consumer report for this purpose concerning my prior employment, military record, education, character, general reputation, personal characteristics, and criminal record. I understand that upon written request to the company, I will be informed whether an investigative consumer report was requested and given full information as to the nature and scope of this investigation. I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information. In consideration of my employment, I agree to comply with the policies and procedures of the company and understand that my employment and compensation can be terminated with or without cause or notice, at any time, at the option of either the company or myself. Date Date Format: MM slash DD slash YYYY SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.