Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.I. Personal Information Name *FirstLastAddress *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Date of Birth *Email Address *If hired, can you provide proof that you are legally able to work in the United States? *YesNoHave you ever been convicted of a criminal offense (felony or misdemeanor)? Note: An affirmative answer will not necessarily result in a disqualification for employment. *YesNoMessageII. Employment Position Desired *Salary Desired *What days and hours are you available for work? *When are you available to begin work? *Are you available to work overtime if necessary? *YesNoAre you over 18 years of age? *YesNoAre you able to perform the essential functions of the job for which you are applying? Note: We comply with the Americans with Disabilities Act and will consider reasonable accommodation measures that may be necessary for eligible applicants to perform essential functions. *YesNoIII. Skills Are you able to operate a personal computer? *YesNoIf yes, what types of computer software do you have proficiency in? *List any other office machines you can operate: *What knowledge, special skills and/ or individual capabilities do you have which especially prepare you for the position applied for? *IV. Education High School or Trade School Name & City of School: *Number of Years Completed: *Did you graduate? *Degree(s) or Diploma(s): *Major Field(s) of Study: *College or University Name & City of School: *Number of Years Completed: *Did you graduate? *Degree(s) or Diploma(s): *Major Field(s) of Study: *V. Employment History Please account for all employment within the last seven (7) years, beginning with your current or more recent employer: Company Name *Company Address *Company Telephone Number *What were the start and end dates of your employment for this position? *Salary *Job Title *Hours and Days Worked *Is this your current employer? *YesNoMay we contact this employer? *YesNoSupervisor *Specific Job Duties *Reason for Leaving * Address Date or Position Held Company Name *Company Address *Company Telephone Number *What were the start and end dates of your employment for this position? *Salary *Job Title *Hours and Days Worked *Is this your current employer? *YesNoMay we contact this employer? *YesNoSupervisor *Specific Job Duties *Reason for Leaving *Position Held Company Name *Company Address *Company Telephone Number *What were the start and end dates of your employment for this position? *Salary *Job Title *Hours and Days Worked *Is this your current employer? *YesNoMay we contact this employer? *YesNoSupervisor *Specific Job Duties *Reason for Leaving *VI. Personal References Please list at least two (2) persons NOT related to you who have known you for at least five (5) years. Name of Reference #1 *Telephone Number *Address *Name of Reference #2 *Telephone Number *Address *Applicant’s Statement (Initial each numbered item as ready) 1. The information that I have provided on this application is accurate to the best of my knowledge and may be verified by Jerry Simcoe Beverage Distributors, Inc. or its agents. *2. I authorize all the schools, persons and organizations named in this application to provide any relevant information in their possession or knowledge to the agents of Jerry Simcoe Beverage Distributors, Inc., for use in deciding whether or not to offer me employment and specifically waive any required written notification I hereby release Jerry Simcoe Beverage Distributors, Inc., my former employers and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such inquiry or disclosure. *3. I understand and agree that any misrepresentation or omission of facts in this application will be justification for refusal or termination of employment, regardless of the time elapsed before discovery. *4. I understand and agree that the employment for which I am applying for is at-will and such employment may be terminated at any time with or without cause, without prior notice, by either myself or Jerry Simcoe Beverage Distributors, Inc.. There will be no agreement, express or implied between Jerry Simcoe Beverage Distributors, Inc. and me for any specific period of employment, nor for continuing or long term employment, unless made in writing, signed by an authorized representative of Jerry Simcoe Beverage Distributors, Inc.. *5. I have placed my signature in the space provided below only after I have completed the entire application to the best of my ability and have carefully read the statements above. *Applicant Name *Applicant Signature *Date *Send Message
