Name* First Middle Last Address* Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Are you 18 years or older?*YesNoPosition applying for: Full-time or Part-time*Full-timePart-timeWhen are you available to start?* MM slash DD slash YYYY What days/times are you available?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM MID PM Desired Wage* What Kelly Express Mart location(s)?* Albion Dimondale Grass Lake Jackson (E. South Street) Jackson (Horton Road) Clark Lake (Jefferson Road) Jackson (South West Avenue) Jackson (Spring Arbor Road,M-60) Jackson (West Michigan Avenue) Jackson (County Farm Road) Lake Odessa Napoleon Vermontville Woodland Check which location(s) you are interested in applying for.Have you previously worked for Kelly Express Marts?*YesNoIf yes, when? What location? Why did you discontinue your employment?Are you employed now?*YesNoMay we contact your present employer?YesNoHave you been convicted of a felony in the last 5 years?*YesNo(Conviction will not necessarily disqualify applicant from employment)If yes, explain and include dates of conviction:Have you ever been a member of the United States Armed Forces?*YesNo If yes, are you currently considered to be on active service?YesNo If no, at time of discharge branch of service and rank: Type of discharge: Date of discharge: MM slash DD slash YYYY If yes, branch of service and rank: Employment HistoryStart with your present or last job.Employer PhoneJob Title Work performedDate employed from MM slash DD slash YYYY Date employed to MM slash DD slash YYYY Supervisor First Last Rate of pay (begin and end) Reason for leaving Employer PhoneJob Title Work performedDate employed from MM slash DD slash YYYY Date employed to MM slash DD slash YYYY Supervisor First Last Rate of pay (begin and end) Reason for leaving Employer PhoneJob Title Work performedDate employed from MM slash DD slash YYYY Date employed to MM slash DD slash YYYY Supervisor First Last Rate of pay (begin and end) Reason for leaving Employer PhoneJob Title Work performedDate employed from MM slash DD slash YYYY Date employed to MM slash DD slash YYYY Supervisor First Last Rate of pay (begin and end) Reason for leaving In case of an emergency we should notify First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneRelationship In case of an emergency we should notify First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneRelationship Applicant's AgreementI UNDERSTAND AND AGREE THAT: I certify that all information given on this application and accompanying documents are true and complete. I understand application forms and all other materials are the property of the Company. I authorize all previous employers, references, the National Personnel Records Center and/or Army, Navy, Marine, Air Force, Coast Guard, National Guard, or their reserve components, driving records, consumer reporting , and any other entity to furnish the Company, the extent permitted by the Federal and State law, my reason for leaving, and all other information they may have concerning me. I release them and the Company from all liability that may arise from such investigation. I understand, if employed, I may terminate my employment at any time without cause, and the Company may terminate or modify the employment relationship at any time without notice or cause. I further understand, if employed, my employment is for no definite period of time and if terminated, the Company is liable only for wages or salary earned as of the date of termination. I understand and voluntarily agree, as a condition of my employment or continued employment, I may be requested by the Company to submit to a urinalysis, drugscreen, alcohol blood analysis and/or other kinds and types of testing, when requested to do so or unsatisfactory test results will disqualify me for consideration for employment, or if I am employed, may result in my immediate termination. By typing my name, I understand and agree: First Middle Last Date MM slash DD slash YYYY
