Last Name Name M.I. Date

Street Address Apartment/Unit #

City State Zip

Phone Cell Phone Email Address

Position applied for:

Can you perform the essential functions of this position for which you are applying? Yes No

If "No", please explain why:

Are you a citizen of the United States? Yes No     If no, are you authorized to work in the U.S.?   Yes No

Are you at least age 18?    Yes   No  (Proof of age and work permits may be required prior to hiring.)

Do you have reliable means of transportation to and from work?    Yes    No

Have you ever worked for Fresco Community Market? Yes   No       If so, when?

How did you hear about Fresco Community Market?

Do you have any relatives working for Fresco Community Market?    Yes    No

If Yes, please provide name(s) and relationship

Have you ever been convicted of a felony?   Yes    No   
If Yes, please explain:

Company Name: Address: Phone Number:
Employed (Month and Year) From: To:
Average number of hours worked per week:
Position held: Supervisor's Name: Position:
Describe all of your significant duties:

May we contact this employer?    Yes    No
Reason for leaving:

Company Name: Address: Phone Number:
Employed (Month and Year) From: To:
Average number of hours worked per week:
Position held: Supervisor's Name: Position:
Describe all of your significant duties:

May we contact this employer?    Yes    No
Reason for leaving:

Company Name: Address: Phone Number:
Employed (Month and Year) From: To:
Average number of hours worked per week:
Position held: Supervisor's Name: Position:
Describe all of your significant duties:

May we contact this employer?    Yes    No
Reason for leaving:

Disclaimer and Signature

By submitting this application, I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.