Lots Job Application Form – Fill Out and Use

Name (Last, First, Middle)

Contact Phone Number

Street Address

City

State

Zip

E-mail Address

Position(s) interested in?

Salary Requirements

Are you under the age of 18?

Yes

No

Hour/Year

(Circle One)

If yes, state your age.

Have you ever worked for Big Lots before?

Yes

No

If yes, when and where?

If hired, can you supply proof that you are legally entitled to work in the United States for any employer?

Yes

No

Do you have friends or relatives working for us?

Yes

No

If so, who?

Can you work:

Anytime

Days

Evenings

Weekends

Are there any times or days you cannot work?

Have you ever been convicted of (1) a violent crime (i.e., assault, battery, murder, etc.), (2) a retail related crime (i.e., shoplifting, credit card fraud, robbery, theft,

burglary, etc.), or (3) drug trafficking/distribution?

Yes

No

Note: A “yes” response will not automatically disqualify you from employment, but will be considered as part of your overall job-related qualifications for

employment. You do not need to disclose any information regarding arrests or any criminal charges and/or convictions that have been erased, annulled, sealed

and/or expunged from your record.

If yes, please describe:

Type of School

Name of School

Location of School

Area of Study

Last Year

Did You Earn a

Completed

Degree or Diploma?

High School

1

2

3

4

Yes

No

College

1

2

3

4

Yes

No

Graduate

1

2

3

4

Yes

No

Other

1

2

3

4

Yes

No

Name of present or last employer

Job Title/Responsibilities

From (Mo. & Yr.)

To (Mo. & Yr.)

Address

Supervisor Name

Was your position

Full time

Part time

City, State, ZIP

Reason for leaving

Terminated

Voluntary

Involuntary

Starting Salary $

Explain

Last Salary $

Phone Number

(

)

Name of previous employer

Job Title/Responsibilities

From (Mo. & Yr.)

To (Mo. & Yr.)

Address

Supervisor Name

Was your position

Full time

Part time

City, State, ZIP

Reason for leaving

Terminated

Voluntary

Involuntary

Starting Salary $

Explain

Last Salary $

Phone Number

(

)

Name of previous employer

Job Title/Responsibilities

From (Mo. & Yr.)

To (Mo. & Yr.)

Address

Supervisor Name

Was your position

Full time

Part time

City, State, ZIP

Reason for leaving

Terminated

Voluntary

Involuntary

Starting Salary $

Explain

Last Salary $

Phone Number

(

)

Name of previous employer

Job Title/Responsibilities

From (Mo. & Yr.)

To (Mo. & Yr.)

Address

Supervisor Name

Was your position

Full time

Part time

City, State, ZIP

Reason for leaving

Terminated

Voluntary

Involuntary

Starting Salary $

Explain

Last Salary $

Phone Number

(

)

Name of previous employer

Job Title/Responsibilities

From (Mo. & Yr.)

To (Mo. & Yr.)

Address

Supervisor Name

Was your position

Full time

Part time

City, State, ZIP

Reason for leaving

Terminated

Voluntary

Involuntary

Starting Salary $

Explain

Last Salary $

Phone Number

(

)

Applicant’s Signature

Date

Your name

Social security number

County

Telephone number

Job applicant’s signature

Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 22851L

Form 8850 (Rev. 1-2012)

Form 8850 (Rev. 1-2012)

Page 2

For Employer’s Use Only

Employer’s name

Telephone no.

EIN

Street address

City or town, state, and ZIP code

Person to contact, if different from above Phil Ownbey c/o First Advantage

Telephone no. (888) 570-4455

Street address 9800 Crosspoint Boulevard, Suite 300

City or town, state, and ZIP code

Indianapolis, IN 46256

Date applicant:

Gave

Was

Was

Started

information

offered job

hired

job

Employer’s signature

Title

Date

Privacy Act and

criminal litigation, to the Department of

The time needed to complete and file

Labor for oversight of the certifications

this form will vary depending on

Paperwork Reduction

performed by the SWA, and to cities,

individual circumstances. The estimated

Act Notice

states, and the District of Columbia for

average time is:

use in administering their tax laws. We

Recordkeeping

. .

6 hr., 27 min.

SECTION REFERENCES ARE TO THE INTERNAL

may also disclose this information to

REVENUE CODE.

other countries under a tax treaty, to

Learning about the law

Section 51(d)(13) permits a prospective

federal and state agencies to enforce

or the form . . . .

. .

. 30 min.

federal nontax criminal laws, or to

employer to request the applicant to

Preparing and sending this form

federal law enforcement and intelligence

complete this form and give it to the

to the SWA . . . .

. .

. 37 min.

agencies to combat terrorism.

prospective employer. The information

If you have comments concerning the

will be used by the employer to

You are not required to provide the

accuracy of these time estimates or

complete the employer’s federal tax

information requested on a form that is

suggestions for making this form

return. Completion of this form is

subject to the Paperwork Reduction Act

simpler, we would be happy to hear from

voluntary and may assist members of

unless the form displays a valid OMB

you. You can write to the Internal

targeted groups in securing employment.

control number. Books or records

Revenue Service, Tax Products

Routine uses of this form include giving

relating to a form or its instructions must

Coordinating Committee,

it to the state workforce agency (SWA),

be retained as long as their contents

SE:W:CAR:MP:T:M:S, 1111 Constitution

which will contact appropriate sources

may become material in the

Ave. NW, IR-6526, Washington, DC

to confirm that the applicant is a

administration of any Internal Revenue

20224.

member of a targeted group. This form

law. Generally, tax returns and return

may also be given to the Internal

information are confidential, as required

Do not send this form to this address.

Revenue Service for administration of

by section 6103.

Instead, see WHEN AND WHERE TO FILE in

the Internal Revenue laws, to the

the separate instructions.

Department of Justice for civil and