Date Received:________ Date Interviewed: ________
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~Employment Application~
Burkholder's Country Market
"An equal opportunity employer"
___________________________________________________________________________________________
Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age,
marital or veteran status, or the presence of a non-job related medical condition or handicap.
(Please Print)
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Name:______________________________________________________________________________________
(Last) (First) (Middle)
Address:____________________________________________________________________________________
(Street Number) (Street) (City) (State) (Zip)
Telephone:__________________ Social Security #: ______-______-______
____________________________________________________________________________________________
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Employment History
Please give accurate and complete information, (full-time and part-time).
Start with most recent job and go back previous two years.
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Company Name:
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Company Telephone Number:
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Company Address:
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Employment Dates:
From: To:
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Name of Supervisor:
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Starting Pay: Ending Pay
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State job title / describe work performed:
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Reason for leaving:
Voluntary: Yes or No (Please circle)
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Company Name:
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Company Telephone Number:
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Company Address:
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Employment Dates:
From: To:
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Name of Supervisor:
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Starting Pay: Ending Pay
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State job title / describe work performed:
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Reason for leaving:
Voluntary: Yes or No (Please circle)
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Company Name:
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Company Telephone Number:
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Company Address:
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Employment Dates:
From: To:
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Name of Supervisor:
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Starting Pay: Ending Pay
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State job title / describe work performed:
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Reason for leaving:
Voluntary: Yes or No (Please circle)
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May we contact the employers listed? Yes or No (Please Circle) If no, whom do you wish us not to contact?
Name: ________________________________ Telephone #: ___________________________
__________________________________________________________________________________________
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Record of Education
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School Type
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Name & Address of
School
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Course of Study
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Last Year Completed
(Please Circle)
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Graduate
(Please Circle)
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Elementary
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_______________
_______________
_______________
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5 6 7 8
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High School
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_______________
_______________
_______________
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9 10 11 12
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Yes or No
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College
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_______________
_______________
_______________
_______________
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1 2 3 4
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Yes or No
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Other
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_______________
_______________
_______________
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1 2 3 4
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Yes or No
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______________________________________________________________________________
Summarize special skills and qualifications you have that may qualify you for the applied for position:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you restricted in on the hours and days you are available for work? Yes or No (Please Circle) If yes please
explain: _________________________________________________________________________
______________________________________________________________________________
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(Applicant Please Read Carefully)
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I agree to comply with all rules of Burkholder's Country Market. I hereby affirm and declare that I have not knowingly
withheld any fact that would, if disclosed, affect my application unfavorably. I hereby authorize Burkholder's Country
Market to conduct any investigation it deems necessary with respect to information set forth on this application. I
also authorize Burkholder's Country Market to release such information together with their opinions on these
matters without any liability for any damage whatsoever caused either directly or indirectly by giving or releasing
such information or opinions. I authorize any former or present employer; schools, colleges and universities, utility
companies, credit, finance bureau offices; personal references and or any other person or persons, to give any
information they have concerning my character, health, credit and employment record. I hereby unconditionally
release any named or unnamed informant from any and all liability resulting from the furnishing of this information.
___________________ ___________________________________________
Date Full Signature of Applicant
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