Bi Mart Application Form – Fill Out and Use This PDF

APPLICATION FOR EMPLOYMENT

Dear Applicant:

We are pleased that you are interested in employment at Bi-Mart. To be considered for possible employment, this application must be accompanied by a signed and dated summary of the position for which you are applying. Please review the position summary thoroughly before completing this application. This Application for Employment will be considered “active” for one (1) month from the date signed.

•PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR ABILITY.

•PRINT LEGIBLY WITH AN INK PEN (OR YOU MAY TYPE THE ANSWERS IF YOU ARE COMPLETING AN ONLINE APPLICATION).

•DONOT LEAVE BLANK SPACES—PRINT N/A (NOT APPLICABLE) WHEN NECESSARY.

AREA OF INTEREST & AVAILABILITY

POSITION

PREFERRED

__________________________________________________________________________________________________________________________ LOCATION:

APPLIED FOR:

FULL TIME

PART-TIME

TEMPORARY/SEASONAL

Have you previously applied for employment at Bi-Mart? YES

NO

When? _______________________________ For what position? _______________________________ What location? _______________________________

PAY EXPECTED:

$ _____________________________

If “Negotiable”, enter range: _____________________________ Date you can start: _____________________________

WE OPERATE 7-DAYS PER WEEK. PLEASE INDICATE WHAT HOURS YOU CAN WORK. WRITE “ANY” IF YOU ARE AVAILABLE ALL HOURS .

AVAILABLE HOURS:

MON: ____________

TUE: ____________ WED: ____________

THU: ____________

FRI: ____________ SAT: ____________ SUN: ____________

REFERRED BY:

NEWSPAPER AD: _______________________________ SCHOOL: _______________________________ INTERNET: _______________________________

(CHECK ONE)

(Specify)

(Specify)

(Specify)

STORE ANNOUNCEMENT:

COMPANY RECRUITER:

OTHER

(Explain): _______________________________________________

PERSONAL INFORMATION

FULL NAME:

____________________________________________________________________________________________ SS#: _________________________________

(LAST)

(FIRST)

(FULL MIDDLE)

ALL OTHER

LAST NAMES USED:

_______________________________________________________________ NICKNAME(S): _____________________________________________________

CONTACT

INFORMATION:

HOME PHONE #: __________________________________________ WORK PHONE #: _________________________________________________________

CELL PHONE #: ___________________________________________ E-MAIL ADDRESS: ________________________________________________________

CURRENT

HOW

MAILING ADDRESS:

_____________________________________________________________________________________________ LONG?

_____________________________

(NO. & STREET)

(CITY)

(STATE)

(ZIP CODE)

CURRENT

STREET ADDRESS:

_____________________________________________________________________________________________

(NO. & STREET)

(CITY)

(STATE)

(ZIP CODE)

PREVIOUS

HOW

STREET ADDRESS:

_____________________________________________________________________________________________ LONG?

_____________________________

(NO. & STREET)

(CITY)

(STATE)

(ZIP CODE)

CITIZENSHIP:

CAN YOU PROVIDE PROOF OF YOUR LEGAL RIGHT TO WORK IN THE U.S.A.? YES:

NO:

PREVIOUSLY

NO:

YES:

IF YES, WHAT LOCATION/DEPT.: ______________________________________________________________________________

EMPLOYED

NAME OF

DATES

BY BI -MART?:

JOB TITLE: _______________________________ SUPERVISOR: _______________________________ EMPLOYED: _______________________________

EDUCATION

SCHOOLSATTENDED		CIRCLE HIGHEST				WHAT NAME(S) ARE	DIPLOMA OR GED
		GRADECOMPLETED				RECORDS UNDER?	YES ( )	NO( )
HIGH SCHOOL ATTENDED:		9	10	11	12
(City)	(State)
COLLEGE/UNIVERSITY OR TECHNICAL/TRADE OR MILITARY		WHAT NAME(S) ARE				DEGREE OR	MAJOR(S)
(Include City and State)		RECORDS UNDER?				CREDITSRECEIVED

LIST ANY CURRENT LICENSES/CERTIFICATES/REGISTRATIONS: ______________________________________________________________________________________________

Are you currently attending school? NO			YES			If YES, what hours / days are you attending? _____________________________________________________________________________

WORK EXPERIENCE

LIST YOUR MOST RECENT JOB FIRST — APPLICANTS MUST PROVIDE A COMPLETE RECORD OF ALL EMPLOYMENT IN THE LAST 15 YEARS . INCLUDE MILITARY SERVICE. AND INDICATE DATES AND REASONS FOR PERIODS OF UNEMPLOYMENT IN EXCESS OF THIRTY (30) DAYS. USE ADDITIONAL SHEETS IF NEEDED.

#1
			DATE EMPLOYED				COMPANY/ORGANIZATION	JOB TITLE/DUTIES PERFORMED	JOB TITLE/DUTIES PERFORMED
			(Month & Year)				(Complete Name & Address)	AT START OF EMPLOYMENT	AT END OF EMPLOYMENT
				/	______________________________________
		MO	YR	MO	YR (Name)
			(FROM)	(TO)
		TYPE OF BUSINESS?			______________________________________
							(Street address)

				______________________________________
				(City)	(State)		(Zip)
	HOWWASPOSITION			AVG. HRS.		SALARY	NUMBER OF	REASON FOR LEAVING OR LOOKING	IMMEDIATESUPERVISOR
	OBTAINED?			WORKED	AT	UPON	PEOPLE YOU	TOLEAVE (BE SPECIFIC)
				PER WEEK	START	LEAVING	SUPERVISED
									NAME: _______________________________________
									TITLE: _______________________________________
									PHONE #: ____________________________________
									MAY WE CONTACT NOW?	YES	NO
#2	DATE EMPLOYED			COMPANY/ORGANIZATION				JOB TITLE/DUTIES PERFORMED	JOB TITLE/DUTIES PERFORMED
	(Month & Year)			(Complete Name & Address)				AT START OF EMPLOYMENT	AT END OF EMPLOYMENT
		/		______________________________________
MO	YR	MO	YR	(Name)
	(FROM)		(TO)
TYPE OF BUSINESS?				______________________________________
				(Street address)
				______________________________________
				(City)	(State)		(Zip)
	HOWWASPOSITION			AVG. HRS.		SALARY	NUMBER OF	REASON FOR LEAVING OR LOOKING	IMMEDIATESUPERVISOR
	OBTAINED?			WORKED	AT	UPON	PEOPLE YOU	TOLEAVE (BE SPECIFIC)
				PER WEEK	START	LEAVING	SUPERVISED
									NAME: _______________________________________
									TITLE: _______________________________________
									PHONE #: _____________________________________
									MAY WE CONTACT NOW?	YES	NO

PAGE 2 OF 4

WORK EXPERIENCE CONTINUED

#3
			DATE EMPLOYED				COMPANY/ORGANIZATION	JOB TITLE/DUTIES PERFORMED	JOB TITLE/DUTIES PERFORMED
			(Month & Year)				(Complete Name & Address)	AT START OF EMPLOYMENT	AT END OF EMPLOYMENT
				/	______________________________________
		MO	YR	MO	YR (Name)
			(FROM)	(TO)
		TYPE OF BUSINESS?			______________________________________
							(Street address)

				______________________________________
				(City)	(State)		(Zip)
	HOWWASPOSITION			AVG. HRS.		SALARY	NUMBER OF	REASON FOR LEAVING OR LOOKING	IMMEDIATESUPERVISOR
	OBTAINED?			WORKED	AT	UPON	PEOPLE YOU	TOLEAVE (BE SPECIFIC)
				PER WEEK	START	LEAVING	SUPERVISED
									NAME: _______________________________________
									TITLE: _______________________________________
									PHONE #: ____________________________________
									MAY WE CONTACT NOW?	YES	NO
#4	DATE EMPLOYED			COMPANY/ORGANIZATION				JOB TITLE/DUTIES PERFORMED	JOB TITLE/DUTIES PERFORMED
	(Month & Year)			(Complete Name & Address)				AT START OF EMPLOYMENT	AT END OF EMPLOYMENT
		/		______________________________________
MO	YR	MO	YR	(Name)
	(FROM)		(TO)
TYPE OF BUSINESS?				______________________________________
				(Street address)
				______________________________________
				(City)	(State)		(Zip)
	HOWWASPOSITION			AVG. HRS.		SALARY	NUMBER OF	REASON FOR LEAVING OR LOOKING	IMMEDIATESUPERVISOR
	OBTAINED?			WORKED	AT	UPON	PEOPLE YOU	TOLEAVE (BE SPECIFIC)
				PER WEEK	START	LEAVING	SUPERVISED
									NAME: _______________________________________
									TITLE: _______________________________________
									PHONE #: ____________________________________
									MAY WE CONTACT NOW?	YES	NO
#5	DATE EMPLOYED			COMPANY/ORGANIZATION				JOB TITLE/DUTIES PERFORMED	JOB TITLE/DUTIES PERFORMED
	(Month & Year)			(Complete Name & Address)				AT START OF EMPLOYMENT	AT END OF EMPLOYMENT
		/		______________________________________
MO	YR	MO	YR	(Name)
	(FROM)		(TO)
TYPE OF BUSINESS?				______________________________________
				(Street address)
				______________________________________
				(City)	(State)		(Zip)
	HOWWASPOSITION			AVG. HRS.		SALARY	NUMBER OF	REASON FOR LEAVING OR LOOKING	IMMEDIATESUPERVISOR
	OBTAINED?			WORKED	AT	UPON	PEOPLE YOU	TOLEAVE (BE SPECIFIC)
				PER WEEK	START	LEAVING	SUPERVISED
									NAME: _______________________________________
									TITLE: _______________________________________
									PHONE #: ____________________________________
									MAY WE CONTACT NOW?	YES	NO

APPLICANTS MUST PROVIDE A COMPLETE RECORD OF ALL EMPLOYMENT IN THE LAST 15 YEARS.

- USE ADDITIONAL SHEETS IF NEEDED -

PAGE 3 OF 4

SKILLS AND INTERESTS

DO NOTinclude the names of clubs, organizations, associations, etc., which indicate the race, creed, religion, age, national origin, political views or any other protected class of it’s members.

List outside activities while in school (athletics, clubs, offices held):

Related hobbies/interests:

Personal aptitudes/interests and technicical/occupational skills (include level of proficiency)

Career aims/goals:

BACKGROUND

TERMINATION: Have you ever been discharged or asked to resign from a job?

*CONVICTIONS: Have you ever been convicted by a criminal or military court of a felony or misdemeanor? This includes criminal traffic and criminal non-traffic offenses, as well as any conviction that has been dismissed pursuant to a civil compromise agreement or the successful completion of a diversion program.

*In most cases, a conviction is not an automatic bar from employment.

COMMENTS

MAKE ANY ADDITIONAL COMMENTS YOU WISH IN THE SPACE BELOW:

ACCEPTANCE

It is the policy of Bi-Mart to recruit, employ, transfer, develop and promote individuals without regard to race, national origin, ancestry, religion, age, gender, gender identity, marital status, disability, or any other protected class as provided by law.

1.I declare that all statements and answers herein are true and complete, and understand that any untruth, misleading answer, omission, concealment, or failure to answer questions fully, completely, and accurately are grounds for termination of employment.

2.I authorize Bi-Mart at any time to investigate my references, to communicate with former employers concerning same, andPAGEto 4 make an independent investigation of my character, conduct, employment, criminal, financial, and driver’s records.

3.I agree that Bi-Mart, my previous employers and any other sources used in this investigation shall not be held liable in any respect if an employment offer is not tendered, is withdrawn, or my employment is terminated due to false statements or answers in this application or any other information gained in this investigation.

4.I have read the Position Summary for the job I am applying for and have submitted a signed copy with this Application.

5.I understand that all applicants considered for employment are required to submit to and pass a pre-employment drug test.

6.I understand that this application for employment is not a contract of employment. All employment at Bi-Mart is strictly

“Employment At Will” which means that an employee may voluntarily end his/her employment at any time with or without notice for any reason, and the company maintains the same right. This relationship cannot be modified by anyone other than in writing by the Senior Vice President of Human Resources or the President of the Company. Any representations by any other person contrary to the “Employment At Will” Doctrine, either verbal or written, shall not be relied upon by any employee.

7.I understand that an original signature on this Application and accompaning pages will be obtained at the time of a face-to-face interview.

________________________________________________________________________________________________________ _
(SIGNATURE OF APPLICANT)	DATE

4 OF 4

EQUIPMENT OPERATOR

Position Overview

Promote a high degree of customer satisfaction within the company. Unload trailers, receive and place incoming freight in specified warehouse area, accounting for the quantity and condition. Fill orders by accurately picking merchandise from warehouse areas. Prepare merchandise for shipping and load into trailers.

•Reports to: Lead equipment operator, supervisor, assistant warehouse manager, and warehouse manager.

•Coordinates with: Lead equipment operator, supervisors, hostlers, drivers, and coworkers.

Essential Job Functions

•Respond to all questions and requests politely and promptly.

•Work as a team with lead equipment operators, supervisors, assistant warehouse manager, warehouse manager, hostlers, drivers, and coworkers to complete daily work assignments.

•Operate all equipment in a safe, efficient, and reasonable manner.

•Unload/load all company trucks and outside carrier trucks quickly and safely.

•Process orders and paperwork quickly, safely, and accurately.

•Ensure all incoming/outgoing freight is accurately received/picked and placed in its proper staging area.

•Keep the warehouse neat, clean, and orderly at all times.

•Perform all pre-shift inspections of equipment and report any problems or malfunctions of equipment to immediate supervisor.

Physical Requirements

Occasionally = up to 1/3 shift

Frequently = up to 2/3 shift

Continuously = throughout shift

•Standing: Frequently in combination with walking on concrete surface.

•Sitting: Continuously while driving sit down forklift. 0% of the time while driving stand up forklift and other warehouse activities.

•Walking: Frequently in combination with standing.

•Worker Mobility: Workers can change positions frequently throughout work shift.

Bi-Mart Corporation

February, 2004

•Carry/Lift: Continuously and independently work with 0-75 pounds depending on product and materials being handled. Continuous carrying/lifting and handling of cased product. Lifting devices and assistance is available for moving greater than 75 lbs. Occasionally required to lift and/or carry in awkward positions while loading and unloading truck trailers.

•Pushing/Pulling: Occasionally and independently push/pull multiple case lots of product on pallet jacks and hand trucks while loading or unloading the truck trailers.

•Bending/Squatting: Continuously while moving freight, verifying merchandise counts, and disposing of cardboard in the prescribed manner.

•Reaching/Handling: Use of fingers/hands/arms continuously. Frequent overhead reaching needed for higher stocking, retrieving, loading, and unloading of truck trailers.

•Grasping/Squeezing: Continuously throughout work shift.

•Twisting: Frequently throughout work shift.

•Climbing: May occasionally climb ladders to reach higher areas. Frequently climbing on and off forklifts.

•Crawling: Occasionally while loading or unloading truck trailers.

•Hearing: Continuously throughout work shift.

Social Skill Requirements

•Positively interact with others.

•Effectively send and receive communication.

Aptitude Requirements

•Must qualify for “Forklift Operator” certification.

•Workers must be able to read and write legibly.

•Perform basic math functions.

•Must have the ability to analyze, reason, and make decisions.

•Must be able to learn and retain new skills.

Environmental Factors

•All work is performed in open warehouse or dock area.

•Continual exposure to outside elements.

•Possible exposure to chemicals and/or compounds throughout work shift.

Bi-Mart Corporation

February, 2004

This position summary covers most of the duties performed, however, other duties and responsibilities not listed may be assigned at the discretion of management.

If no to the above, please identify any functions that you are unable to perform:

I verify that I have thoroughly reviewed the position summary for Equipment Operator and that I understand the job requirements and essential job functions.

Signature: ___________________________________________________ Date: _______________________

Print Name: __________________________________________________

Bi-Mart Corporation

February, 2004