Vallarta Market Job Application Form – Fill Out and Use

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION		MUST BE AT LEAST 18 YEARS OF AGE TO APPLY					Date Completed: ______________
Last Name		First Name					Middle Name
Present Address Number	Street Name		City			State	Zip Code	Years at Address
Phone Number		Secondary Phone #
Person to notify in case of an Emergency: Name		Address	Street		City	State	Zip Code	Home Telephone Number
Do you have any relatives working for the company? Yes			No
Name_______________________________________Position___________________________________Location ________________________________
EMPLOYMENT INFORMATION
Where did you submit application?					Have you applied for Vallarta Supermarkets in the past 90 days? Yes No
San Fernando Valley	N. San Joaquín	Whittier/Downey			If Yes, when? (Month/Year) ____________________________________
Antelope Valley	S. San Joaquín	Pasadena
Victorville/Hesperia	Corporate				If Yes, at which location? ______________________________________

Vallarta Supermarkets offers many opportunities within our Company. Which Department(s) would you enjoy working in?

STORE OPPORTUNITIES:

Bakery Cashier Courtesy Clerks Customer Service Booth Deli/Dairy/Frozen Meat/Cremería Produce Taqueria Tortilleria Grocery Receiving Scan Janitorial

Option #1 Position Applying For: _____________________________ Option #2 Position Applying For: _____________________________

List skills relevant to the position(s) you are applying for: ______________________________________________________________________________

________________________________________________________________________________________________________________________

What type of employment are you looking for?			Full Time or	Part Time	Are you currently employed?		Yes No
May we contact your current employer?		Yes	No		If hired do you intend to keep your present job? Yes			No
Specify hours available for each day of the week (if available anytime write ANY):
_______________	_______________	_______________		_______________		_______________	______________	_______________
Monday	Tuesday		Wednesday	Thursday		Friday	Saturday	Sunday
Have you ever worked for Vallarta Supermarkets before? Yes				No If “yes,” give dates From ____/____/___ To ___/___/___ Location: _______________

Reason for leaving Vallarta Supermarkets? _________________________________________________________________________________________

Are you able to perform the essential functions of the job for which you are applying, either with or without a reasonable accommodation? Yes No If “no, describe the functions that cannot be performed. __________________________________________________________________________________

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

WORKING SAFELY IS A CONDITION OF EMPLOYMENT

Vallarta Supermarkets is committed to providing a safe, healthy and secure work environment for our team members and customers through

our Work Safe programs. We achieve our Work Safe goals through partnership with our team members, managers and leadership. Vallarta Supermarket’s Work Safe programs are based upon the following principles:

Work Injuries and illnesses are preventable and we have a clear goal to achieve zero injuries.

Safety is everyone’s responsibility

Working safely is a condition of employment

Compliance with all applicable health and safety requirements is paramount.

The integrity of our Work Safe programs is ensured through sensible hiring, and comprehensive ongoing safety training that begins on every team member’s first day. At Vallarta Supermarkets, our work is never too urgent or too important so that we cannot take the time

to do it safely.

Vallarta is an equal opportunity employer. Vallarta provides equal employment opportunity for all applicants and prohibits discrimination based on race, color, sex (including pregnancy, childbirth, breastfeeding and medical conditions related to pregnancy, childbirth, or breastfeeding), gender, religious creed (including religious dress and grooming practices), marital status, domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic information and characteristics, sexual orientation, gender identity or expression, military or veteran status, or any other basis protected under federal, state, or local laws.

Vallarta will make reasonable accommodations, where appropriate, to assist applicants with disabilities with Vallarta’s application and hiring processes, if the accommodation does not result in an undue hardship to the Company or a direct threat to health and safety.

WORK EXPERIENCE

*Last/Present Employer:

Reason for leaving or wanting to leave?

Length of Service

Address

Month/Year

Month/Year

Present job title or job title at the end of employment:

Began

Ended

Telephone Number(s)

Job title when you began:

Name of Supervisor

Major responsibilities:

Title

Department

May we contact now?

Yes

No (If still employed)

*Last/Present Employer:

Reason for leaving or wanting to leave?

Length of Service

Address

Month/Year

Month/Year

Present job title or job title at the end of employment:

Began

Ended

Telephone Number(s)

Job title when you began:

Name of Supervisor

Major responsibilities:

Title

Department

May we contact now?

Yes

No (If still employed)

*Last/Present Employer:

Reason for leaving or wanting to leave?

Length of Service

Address

Month/Year

Month/Year

Present job title or job title at the end of employment:

Began

Ended

Telephone Number(s)

Job title when you began:

Name of Supervisor

Major responsibilities:

Title

Department

May we contact now?

Yes

No (If still employed)

EDUCATION

Name and Address

Circle Years

Did You

Completed

Graduate?

High School

1

2

3

4

College

1

2

3

4

Post College

1

2

3

4

Trade or Business School

1

2

3

4

APPLICANT’S STATEMENT

PLEASE READ CAREFULLY BEFORE SIGNING!

I hereby certify the information on this application is correct and complete to the best of my knowledge.

I understand that falsification or omission of any material information on this application shall be grounds for rejection of this application or for immediate termination. I authorize the references listed to provide the Company any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any use or disclosure of such information by the Company or any of its agents, employees, or representatives. I agree that if employed, I will abide by all policies and procedures established by the employer. I agree to submit to Drug Testing if required, by Vallarta Supermarkets.

I hereby acknowledge that my employment is “at-will,” that I may resign at any time and the Company may terminate my employment at any time, with or without cause, and with or without notice, that any assurances of continued employment, whether written, oral or by conduct, shall not be interpreted as changing the nature of the employment relationship unless specifically acknowledged in writing by the President of the Company.

I declare under penalty of perjury that all the foregoing is true and correct

	_______________________________	___________________________
Signature of Applicant	Print Name	Date

Note: No consideration of employment will be given to any applicant that does not sign the above statement. Application expires in 90 days if not employed.

FOR COMPANY USE ONLY

HR Prescreened process:				[ ] Yes	[ ] No		Employee Number:___________
Pre-screen done by: _________________________							Full Time [ ]	Part Time [ ]
Starting Date:							Location # _________________
Department #:				Job Title: _____________________________ Salary: $___________ Vacation Code: _______
Remarks:

I hereby certify that I have been informed of the duties, the hours and days of work of the position for which I was offered and accepting.

	______________________________	_______________________
Employee Signature	Print Name	Date
	______________________________	_______________________
Authorized Hiring Person Signature	Print Name	Date

Position

Orientation Date _____________________