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Personal Information
Application Date*
MM slash DD slash YYYY
Name*
First Middle Last
Current Address*
Street Address City State ZIP Code
Phone Number
Email Address*
If hired, can you provide evidence of legal eligibility to work in the U.S.?*
- Yes
- No
Any offer of employment is conditioned upon completing form I-9 and providing the appropriate documents for identity and work authorization.
Position Desired*
Wage/Salary Desired
What kind of work schedule is desired?*
- Full Time
- Part Time
Date you can begin work
MM slash DD slash YYYY
Are you 18 years or older?
- Yes
- No
If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by state or federal law
Educational History
Name of High School attended
City/State
Did you graduate?
- Yes
- No
GED?
- Yes
- No
Name of college or technical school
City/State
Degree?
- Yes
- No
Major
Are you presently enrolled in school?
- Yes
- No
If yes, give name & address of school and expected degree date:
List any job-related skills or accomplishments, including military service
Your Availability for Work
Monday
List From: and To: times
Tuesday
List From: and To: times
Wednesday
List From: and To: times
Thursday
List From: and To: times
Friday
List From: and To: times
Saturday
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Sunday
List From: and To: times
Total hours per week you are available to work
Do you have any special requests or needs for a work schedule?
References
Provide three references who are not former employers who we may contact
1. Name and Occupation
How do you know them, and for how long?
Phone Number
2. Name and Occupation
How do you know them, and for how long?
Phone Number
3. Name and Occupation
How do you know them, and for how long?
Phone Number
Your Employment History
List names of employers with present or last employer listed first
May we contact current employers before you are offered a position?
- Yes
- No
1. Name of Employer
Job Title
Dates of Employment (From: and To:)
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Duties
Name of Supervisor
First Last
Phone Number
Reason for Leaving
Starting pay
Ending pay
2. Name of Employer
Job Title
Dates of Employment (From: and To:)
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Duties
Name of Supervisor
First Last
Phone Number
Reason for Leaving
Starting pay
Ending pay
3. Name of Employer
Job Title
Dates of Employment (From: and To:)
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Duties
Name of Supervisor
First Last
Phone Number
Reason for Leaving
Starting pay
Ending pay
*
- I have read and understood all of this application.
Date*
MM slash DD slash YYYY
Signature or Typed for Digital Application*

71658

Contact Information

507-798-2424
Monday: Closed
Tuesday: 4:00PM–9:00PM
Wednesday: 11:00AM–Close
Thursday: 11:00AM–Close
Friday: 11:00AM–Close
Saturday: 11:00AM–Close
Sunday: 11:00AM–8:00PM
411 Division St
Millville, Minnesota 55957

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411 Division St
Millville, Minnesota 55957

507-798-2424

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