LeBlanc's Food Store - Employment Application

PERSONAL INFORMATION
Date:	02/05/2012
Last Name:
First Name:
Middle:
Home Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
If you're under 18 years of age, please state your date of birth	(dd/mm/yyyy)
Are you interested in: (check all that apply)	Full-Time Part-Time
Date Available to Start:
Store Location in which you are applying to:	Donaldsonville Gonzales Hammond Plattenville Plaquemine Prairieville Walker Zachary
Position you are applying for:

EDUCATION
Type of School	School & Location of School	School/Community Activities	Current Year in School	Graduated
High School	School			Yes	No
	City
College	School			Yes	No
	City
Graduate School	School			Yes	No
	City
Other	School			Yes	No
	City

LEGAL
Are you a U.S. citizen or do you have a legal right & necessary documents to work in the U.S.? Yes No
Were you ever discharged by any company? Yes No
If yes, give name of company(ies)
Have you ever been convicted of a crime other than a minor traffic violation? (Note: you are not obligated to discuss sealed or expunged records of conviction or arrest nor will such information be asked of you or considered in employment decisions.) The existence of a criminal record will not automatically disqualify you from the job for which you are applying. Yes No
If yes, please explain offense and final disposition

EMPLOYMENT HISTORY
Please list all employment starting with your most recent employer. Include military assignments, part-time and/or volunteer activities.
Employer
Position
Date Started
Date Ended
Starting Salary/Wage
Final Salary/Wage
Address
Name of Supervisor
Telephone Number of Supervisor
May We Contact?	Yes No
If no, please explain
Reason for Leaving

Employer
Position
Date Started
Date Ended
Starting Salary/Wage
Final Salary/Wage
Address
Name of Supervisor
Telephone Number of Supervisor
May We Contact?	Yes No
If no, please explain
Reason for Leaving

Employer
Position
Date Started
Date Ended
Starting Salary/Wage
Final Salary/Wage
Address
Name of Supervisor
Telephone Number of Supervisor
May We Contact?	Yes No
If no, please explain
Reason for Leaving
Have you ever worked at a LeBlanc’s Food Stores location?	Yes No
If yes: What Location? And When?

AVAILABILITY
Please list the days & times you are available to work. If you are able to work anytime, write the word "Anytime" across the box. List the Reason for each day if there is a reason you are unable to work certain times. Remember: Our regular store hours are from 7:00 a.m. until 9:00/10:00 p.m. 7 Days A Week
	Example	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From	3:00 p.m.
To	9:00 p.m.
Reason	School
PLEASE READ CAREFULLY In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate dismissal. I understand, also, that I am required to abide by all rules and regulations of LeBlanc's. I understand and agree that if employed, the employment will be "at will." That is, either I or LeBlanc's may end the employment relationship at any time, for any reason, or for no reason. I understand that receipt of this application by LeBlanc's does not imply employment and that this application and/or any other LeBlanc's documents are not contracts of employment. I certify by checking this box that I have read the above paragraph and that all information entered on my application is accurate. >> SUBMIT >> >> RESET >>