Application Form

APPLICANT INFORMATION
Last Name
First Name
Middle Initial
Today's Date
Email Address
Street/P.O. Box
Apt. #
City
State
ZIP Code
Day Phone No.
Evening Phone NO.
Social Security Number
Expected Hourly Pay Rate
Do you have reliable transportation to and from work during our hours of operation?
Yes No
Are you applying for a full-time or part-time position?
Full-Time Part-Time
How many hours per week do you want to work?
Minimum Maximum
Position Applying For:
Driver's License Number (if applicable to position)
Driver's License State
Date available for work
How did you learn about this position?

An Equal Opportunity Employer

It is the policy of Membership Auto® not to discriminate and to provide equal employment opportunities to all qualified persons regardless of race, color, creed, national origin, sex, age, marital status, sexual orientation, or citizenship status. We shall continue to provide equal employment opportunity to Veterans of the Vietnam Era and to disabled Veterans and individuals with disabilities except where the disability is a bonafide occupational disqualification.


EDUCATION
Type of School Name and Location of School Degree/Area of Study Number of Years Attended Graduated (check one)
High School
Name
Address

City
State
Zip
Yes No
College
Name
Address

City
State
Zip
Yes No
Graduate School
Name
Address

City
State
Zip
Yes No
Other
Name
Address

City
State
Zip
Yes No

EMPLOYMENT HISTORY
(LIST PRESENT OR MOST RECENT POSITIONS FIRST)
Company
Phone
Address
Name and Position of Supervisor
Job Title
Starting Salary
$
Ending Salary
$
Responsibilities
Company
Phone
Address
Name and Position of Supervisor
Job Title
Starting Salary
$
Ending Salary
$
Responsibilities
Company
Phone
Address
Name and Position of Supervisor
Job Title
Starting Salary
$
Ending Salary
$
Responsibilities

MEDICAL HISTORY
Date of last health exam
Purpose
Are you willing to take a physical exam? Yes No
How much have you lost through illness in the past 2 years?
What was the reason?
Do you have any physical impairment? Yes No
If you answered yes above, explain.
1. If hired, can you submit documents to prove your legal right to work in the U.S? Yes No
2. We does not tolerate drug use by employees before or during work.
are you willing to comply?
Yes No
3. Up to 50 lbs. of lifting several times a day is an essential for most positions.
Are you willing and able to comply with this requirement?
Yes No
4. Being on your feet for 6-9 hours at a time is a requirement in most positions.
Are you willing and able to comply with this requirement?
Yes No
5. Have you ever applied for a position at this company or an affiliated company before? Yes No
If yes, which location?
What was the result?
6. Have you ever been employed by this company or an affiliated company before? Yes No
If yes, which company?
When? From: / To: /
What was your position?
Why did you Leave?
7. Are you a U.S Citizen? Yes No
8. Are you legally allowed to work in the United States? Yes No
9. Have you ever been convicted of a crime? Yes No
If yes, what are the dates and the details?
10. If selected for employment are you willing to submit to a pre-employment drug screening test? Yes No

ACKNOWLEDGEMENT AND AUTHORIZATION
I certify that all answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

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