Weis Employment Application – Fill Out and Use

weis Application for Employment

Weis Markets is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of actual or perceived age, sex, sexual orientation, race, color, creed, religion, familial status, ethnicity, national origin, alienage or citizenship, disability, marital status, military or veteran status, or any other legally recognized protected basis under federal, state or local laws, regulations or ordinances. Applicants with a disability may be entitled to reasonable accomodation under terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accomodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on Weis Markets. Please inform a Company representative if you need assistance completing any forms or to otherwise participate in the application process.

This application will remain active for 60 days, after 60 days, you must reapply for further consideration.

	PLEASE PRINT CLEARLY		DATE ______________________
	(USE PEN ONLY)
	PERSONAL DATA
NAME_____________________________________________________________________________________________________
last	first		middle initial
ADDRESS__________________________________________________________________________________________________
street	city	state	zip
TELEPHONE ( ________ )___________________________ SOCIAL SECURITY NO.__________________________________
area code	number

You should answer “no record” if a conviction has been sealed or expunged or otherwise statutorily eradicated. If you checked yes, please explain below. If more space is required, please use seperate sheet. A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe the nature of the crime and your subsequent rehabilitation.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

EMPLOYMENT AVAILABILITY

Position(s) applied for_______________________________________________ Date you can start____________________________

month/day/year

Wages desired? $______________per hour, or $______________per week

We are a 7-day-a-week business with emphasis on nights and weekends. Please indicate your availability below:

Put the specific hours (From/To) you are available for work in the boxes below. (Leave the box empty if you are not available at all that day and write “A” under any day you are “available” all that day without any scheduling restrictions.)

SUN

MON

TUE

WED

THU

FRI

SAT

From (AM/PM)

To (AM/PM)

Form #45 Revised 6-1-04

				EDUCATION
Name and location of school			Circle highest year				Graduated	Degree/Major
				completed
High School or GED			9	10	11	12	YES
NAME:
							NO
ADDRESS
College or University			FR	SO	JR	SR	YES
NAME:
							NO
ADDRESS
Other (Specify)			1	2	3	4	YES
NAME:
							NO
ADDRESS
Are you now enrolled? YES	NO	If yes, name and location of school__________________________________
Availability during school vacations: FULL		PART		NONE

Other education, training, skills or hobbies relevant to employment consideration________________________________

___________________________________________________________________________________________________________

EMPLOYMENT HISTORY

*Beginning with the most recent employment, list the last four employers (including military service) or cover at least a seven year period, whichever is longer. Use seperate sheet if necessary.

Current or Most Recent Employer	Phone (	)	From		To
			Mo.	Yr.	Mo.	Yr.
Street			Base Salary or Wage
			Starting		Ending
City	State	Zip	Supervisor’s Name
Job Title and Duties			Reason for leaving
Previous Employer	Phone (	)	From		To
			Mo.	Yr.	Mo.	Yr.
Street			Base Salary or Wage
			Starting		Ending
City	State	Zip	Supervisor’s Name
Job Title and Duties			Reason for leaving
Previous Employer	Phone (	)	From		To
			Mo.	Yr.	Mo.	Yr.
Street			Base Salary or Wage
			Starting		Ending
City	State	Zip	Supervisor’s Name
Job Title and Duties			Reason for leaving
Previous Employer	Phone (	)	From		To
			Mo.	Yr.	Mo.	Yr.
Street			Base Salary or Wage
			Starting		Ending
City	State	Zip	Supervisor’s Name
Job Title and Duties			Reason for leaving

*ALL employment information above must be completed in full for your application to be considered.

In the past seven years have you ever been discharged, suspended or asked to resign by an employer? YES

NO

If yes, give employer name, date of action, and reason _________________________________________________________________

___________________________________________________________________________________________________________

If yes, and not included above, give dates employed, position, any other name used and reason for leaving________________________

___________________________________________________________________________________________________________

For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the

organizations you have listed? YES NO

If yes, specify name _________________________________________________________________________________________

REFERENCES

List two professional references familiar with your work ability (exclude relatives)

Full Name (not related to you)						Full Name (not related to you)
Address	Street		City	State	Zip	Address	Street	City	State	Zip
Phone		Occupation				Phone		Occupation
How acquainted and for how long?						How acquainted and for how long?

READ CAREFULLY AND SIGN

PLEASE READ THESE STATEMENTS OVER CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING AT THE BOTTOM

I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.	____________Initials
I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after
receiving a conditional offer of employment, and must receive a negative result before being permitted to commence
work with Weis Markets.	____________Initials
I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical
examination after receiving a conditional offer of employment, and must meet the qualifications for the position,
with or without reasonable accommodation, before being permitted to commence work with Weis Markets.	____________Initials
I hereby certify that the information given by me is true in all respects. I authorize Weis Markets and its representatives
to contact my prior employers and all others for the purpose of verification of the information I have supplied and
release same from any liability resulting from the information released. I authorize employers, schools and other
persons named on this application to provide any information or transcripts requested.	____________Initials
I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual
consent and may be terminated at will, with or without cause, by either party (the employer or me) without prior
notice to the other, unless otherwise prohibited by law.	____________Initials
I understand that no representation, whether oral or written, by any representative or agent of Weis Markets, at any time,
can constitute an implied or expressed contract of employment. I further understand no representative or agent of
Weis Markets, has the authority to enter into an agreement for employment for any specified period of time or to make
any change in any policy, procedure, benefit or other terms or condition of employment other than in a document signed
by the Director of Human Resources or his/her authorized representative.	____________Initials

FOR MARYLAND APPLICANTS ONLY:

Maryland lie detector law - “Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not exceeding $100.”

	Acknowledgment of Maryland Lie Detector Law: _______________________________________________________	Date___________________
	Maryland applicants signature required.
I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any falsification
or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time
lapse before discovery.		____________Initials

Note: An offer of employment is conditioned upon complying with Weis Markets’ requirements including, but not limited to signing a Consent to Conduct an Investigation.

MY SIGNATURE IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS

Applicant’s signature __________________________________________________________________ Date____________________________

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