APPLICATION FOR EMPLOYMENT
(Non-California Applicants ONLY)
To learn more & join the Safeway team visit Safeway.com
AN EQUAL OPPORTUNITY EMPLOYER
The Safeway policy is to provide employment, training, compensation, promotion and other conditions of employment without regard to race, color, religion, sexual orientation, national origin, sex, age, disability, veteran or any other legally protected status. Applicants must reapply at least once every two months to remain under consideration for employment.
PERSONAL INFORMATION
NAME |
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TEL. NO. ( |
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First |
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OTHER NAMES USED FOR EMPLOYMENT OR EDUCATION (if any) |
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SOCIAL |
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ADDRESS |
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SECURITY NO. |
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Street/Apt. # |
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ZIP |
County |
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FOR WHAT POSITION(S) ARE YOU APPLYING? |
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FULL-TIME |
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PART-TIME |
EITHER |
PREFERRED FACILITY/STORE? |
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ARE YOU UNDER THE AGE OF 18? |
YES |
NO |
IF UNDER 18, STATE YOUR AGE |
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ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? |
YES |
NO |
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HAVE YOU WORKED FOR SAFEWAY OR ONE OF ITS AFFILIATED COMPANIES LISTED AT THE TOP OF THIS APPLICATION? |
YES |
NO |
WHEN? |
WHERE? |
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POSITION HELD? |
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REASON FOR LEAVING? |
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LIST THE NAMES OF RELATIVES EMPLOYED BY ANY OF THE SAFEWAY COMPANIES AND THEIR WORK LOCATION |
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NONE |
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NAME |
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RELATIONSHIP |
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WORK LOCATION |
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1.) |
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2.)
3.)
FOR APPLICANTS OUTSIDE OF HAWAII:
HAVE YOU BEEN CONVICTED OF A CRIME WITHIN THE LAST TEN (10) YEARS (other than a minor traffic violation)? YES NO Hawaii applicants do NOT answer this question.
IF YES, STATE THE DATE, LOCATION, NATURE AND DISPOSITION OF THE OFFENSE:
(A “Yes” answer will not necessarily disqualify you from employment.)
*FOR HAWAII APPLICANTS: If you are made a conditional offer of employment, you will be asked to provide information regarding criminal convictions prior to hiring.
DATE AVAILABLE FOR WORK |
TOTAL HOURS AVAILABLE PER WEEK |
(You may list time needed for religious practices/observances as “available” time.) The majority of retail store shifts are afternoons, evenings and weekends.
SUN |
MON |
TUES |
WED |
THURS |
FRI |
SAT |
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Earliest Time
Latest Time
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APPLICATION FOR EMPLOYMENT |
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(Non-California Applicants ONLY) |
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To learn more & join the Safeway team visit Safeway.com |
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EDUCATION |
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NAME & ADDRESS OF SCHOOLS ATTENDED |
FROM |
TO |
CIRCLE HIGHEST |
DEGREE/MAJOR |
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mo/yr |
mo/yr |
GRADE/LEVEL COMPLETED |
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HIGH SCHOOL
9 10 11 12
COLLEGE
1 2 3 4
GRADUATE
1 2 3 4
OTHER
1 2 3 4
RECORD OF U.S.A. MILITARY AND RESERVE STATUS
Service Dates |
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FROM mo |
yr |
TO mo |
yr |
Branch |
Reserve Unit |
Meeting Dates |
Summarize skills, training or qualifications: |
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PROFESSIONAL/PERSONAL REFERENCES |
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NAME |
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ADDRESS |
PHONE NUMBER |
OCCUPATION |
1.) |
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2.) |
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EMPLOYMENT HISTORY
List each job held during the last seven (7) years with a minimum of three (3) employers. Start with your present or last job. Also, include any periods of unemployment, military service, and volunteer and/or part-time work experience. If necessary, use an additional sheet to include related work history beyond seven (7) years.
EMPLOYMENT |
COMPANY AND |
SUPERVISOR’S |
DATES (mo/yrs) |
MAILING ADDRESS |
NAME/PHONE |
FROM |
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FROM |
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FROM |
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FROM |
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FROM |
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SALARY |
YOUR JOB TITLE |
SPECIFIC JOB DUTIES |
REASON FOR |
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LEAVING |
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START |
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FINAL |
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START |
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FINAL |
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START |
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FINAL |
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START |
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FINAL |
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START |
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FINAL |
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Have you ever been fired from a job or given an opportunity to resign? |
Yes |
No |
If yes, Explain: |
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READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE THE APPLICATION
Please initial each of the following paragraphs:
Certification: I certify that the information I provided on this application is true and correct to the best of my knowledge, and I agree to have this information checked by the Company. I authorize the references listed to provide the Company with information about my previous employment and any other information they may have. I release all parties and persons, including the Company, from any and all liability for any damages for providing this information, consistent with state and federal law.
At-will employment: I understand that nothing in this application is intended to be, or is, an offer of employment or a promise of continued employment. I understand that if I become employed by the Company, my employment is for no specific term. I further understand that, except for any periods of time that I am employed in a position covered by an express written agreement that provides otherwise, my employment with the Company may be terminated at any time, with or without cause and/or notice, at the will of either me or the Company. I further understand that no Company representative has any authority to enter into any agreement with me different or contrary to the foregoing.
Eligibility verification: I understand that any false statement or omission on this application may prevent me from receiving an offer of employment, may result in a withdrawal of an employment offer, or may result in my discharge from employment if I am already employed at the time the false statement or omission is discovered.
I understand that any offer of employment is conditioned on satisfactory proof of my identity, that I am of legal age, and that I have legal authorization to work in the United States. I also understand that this may include the Company’s receipt of satisfactory responses to reference requests, my passing of any required drug screening test, satisfactory completion of a background check, if applicable, and satisfactory completion of a post-offer medical examination, if applicable.
Applicant Signature |
Date |
Interviewer’s Signature |
Date |
APPLICATION FOR EMPLOYMENT
(Non-California Applicants ONLY)
To learn more & join the Safeway team visit Safeway.com
APPLICATION INFORMATION
To be completed by Applicant |
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NAME (Required) |
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First |
Middle Initial |
Last |
Race/Ethnic Group |
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Application Date |
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Source Code |
SELECT ONLY ONE |
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Month |
Day |
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Year |
Walk-in |
American Indian/Alaskan Native |
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Jan |
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2005 |
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Newspaper Advertisement |
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Employee Referral |
Asian |
Feb |
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2006 |
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Native Hawaiian/ |
Mar |
0 |
0 |
2007 |
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Employment Agency |
Other Pacific Islander |
Apr |
1 |
1 |
2008 |
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Female/Minority Group Referral |
Black/African American |
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May |
2 |
2 |
2009 |
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Community/Vocational Rehab Org |
Hispanic/Latino |
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Jun |
3 |
3 |
2010 |
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High School/College Referral |
White |
Jul |
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4 |
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Job Fair/Recruiting Event |
Two or More Races |
Aug |
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5 |
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Internal Postings |
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6 |
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Sep |
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Job Postings |
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Decline Disclosure |
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7 |
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Oct |
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Other (Explain) _______________ |
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8 |
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Nov |
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____________________________ |
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9 |
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Gender |
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Internal Employee Application |
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Dec |
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Male
Female
Decline Disclosure
TO BE COMPLETED BY HIRING PERSONNEL ONLY
(mark appropriate boxes)
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Job Group Codes |
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Disposition Codes |
1B Assistant Store Managers |
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A = No position available within the last 60 days |
1C Department Managers |
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B = More qualified applicants available |
1D Head Clerks |
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C = Unavailable to work required hours |
1E |
Pharmacy Manager |
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D = Available type of work was not acceptable |
1F |
Supply Manager/Supervisor |
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E = Unable to contact/unavailable for interview |
1G Backstage Manager |
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F = Wage not acceptable |
1H Distribution Manager |
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G = Did not meet post-offer policy requirements |
2A |
Pharmacist |
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H = Declined job offer |
2B Professionals |
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I = Did not show up for interview |
3A |
Technician |
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J = Ineligible for rehire |
4A |
Food Clerks: Jny/App/Produce |
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K = Did not pass pre-employment test |
4B Service Departments |
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L = Hired |
4C Courtesy/Helper Clerks |
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M = Other |
5A |
Senior Clerical |
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5B Clerical |
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6A |
Crafts, Skilled |
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7A |
Operators, Semi-Skilled |
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8A |
Laborers, Unskilled |
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9A |
Service Workers |
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Interview Date
Month |
Day |
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Year |
Jan |
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2005 |
Feb |
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2006 |
Mar |
0 |
0 |
2007 |
Apr |
1 |
1 |
2008 |
May |
2 |
2 |
2009 |
Jun |
3 |
3 |
2010 |
Jul |
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4 |
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5 |
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Aug |
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6 |
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Sep |
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7 |
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Oct |
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8 |
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Nov |
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9 |
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Dec |
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NOTICE AND CONSENT CONCERNING CONSUMER REPORTS
AND INVESTIGATIVE CONSUMER REPORTS
This form, which you should read carefully before signing, has been provided to you because Safeway Inc. (“the Company”) may request consumer reports or investigative consumer reports from USIS Commercial Services, Inc. (“USIS”) in connection with your application for employment or, if you are or become employed by the Company, during the course of your employment with the Company. Such reports may be requested for purposes of evaluating your suitability for employment, promotion, reassignment, retention or other employment-related purposes.
The types of reports that the Company may request from USIS include, but are not limited to: credit reports, criminal records checks, court records checks, driving records, and/or summaries of educational, employment records and histories, and investigative consumer reports (reports with information regarding your character, general reputation, personal characteristics or mode of living). The information contained in these reports may be obtained by USIS from public record sources, educational institutions, USIS clients, or through personal interviews with your co-workers, neighbors, friends, associates, current or former employers, or other people you know. You have the right to request additional disclosures of the nature and scope of the investigation by USIS and a statement of your rights. To receive this information or to inspect any files concerning such a report or to determine if a report on you has been requested, you may contact USIS by mail at 4500 S. 129th East Avenue, Suite 200, Tulsa, Oklahoma 74153, by phone at (800) 331-9175 or by fax at (918) 627-6162.
If any adverse decision with regard to your application for employment with the Company or, if you are hired, during the cours of your employment, is based in whole or part on the information contained in a consumer report or an investigative consumer report, you will be notified as to the basis for the decision and given a copy of the report, as well as a summary of your applicable rights.
CONSENT TO CONSUMER REPORTS AND INVESTIGATIVE CONSUMER REPORTS
I have carefully read and understand the Notice Concerning Consumer Reports and Investigative Consumer Reports and this Consent to Consumer Reports and Investigative Consumer Reports (“Consent”) and, by my signature below, I authorize USIS to release consumer reports and/or investigative consumer reports, as described above, to the Company: (1) in conjunction with my application for employment and (2) during the entire course of my employment. I further understand that any and all information contained in my job application or otherwise disclosed to the Company by me before or during my employment may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by the Company, and I confirm that all such information provided in connection with my job application is true and correct. I also agree that a facsimile, photocopy or electronic copy of this form may be used in lieu of the original.
I also authorize the following entities to disclose to USIS and its agents all information about or concerning me, including, but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and, any other person, organization or agency with any information about or concerning me. The information that can be disclosed to USIS and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, drug test results, military service, professional credentials, and all other information requested by USIS or its agents.
NOTICE TO WASHINGTON STATE APPLICANTS OR EMPLOYEES
If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the right to ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
NOTICE TO WASHINGTON STATE APPLICANTS OR EMPLOYEES
If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the right to ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
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Name of Applicant (Print) |
Date |
Applicant or Employee Signature |
Social Security Number |
Street Address |
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City, State and ZIP Code |
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1/2008
