River Country Co-op Employment Application

1080 W River Street Chippewa Falls, WI 54729 - Phone: 723-2828 or 1-800-828-9395 Fax 715-723-4733

Qualified applicants are consider for all positions without regard to race, color, religion,
gender, national origin, age, marital or veteran status, or any legally protected status.

Job you are applying for:
Store or Location:
How did you learn about us?
Advertisement Relative Inquiry
Employment Agency Friend Other
First Name: Middle Initial: Last Name:
Address: City: State: Zip:
Telephone Number: Alternative Telephone Number:
Best time to contact you at home is................... E.G. 6:00pm
If you are under 18 years of age, can you provide required proof of your eligibility to work?....... Yes No
Have you ever filed an application with us before?........... Yes No -- If Yes, give date: E.G 2/28/2010
Have you ever been employed with us before?................. Yes No -- If yes, give date: E.G 2/28/2010
Do any of your friends or relatives, other than spouse, work here?.... Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No
Proof of citizenship or immigration status will be required upon employment.
Date available for work: What is your desired rate of pay?

Are you available to work:

  • Full-Time (please fill in blank with 1st, 2nd, or 3rd shift)
  • Part-Time (please indicate Mornings Afternoon Evenings in the blank)
  • Temporary (please indicate dates available in the blank)
  • Any (please indicate shift or time you are NOT available)
Hours per week preferred:
Have you ever been convicted or pled guilty to any crime involving violence to another person?......... Yes No
Have you ever been convicted or pled guilty to any crime involving retail theft, fraud, or embezzlement?......... Yes No
Have you ever been convicted or pled guilty to any crime involving distribution of illegal drugs or controlled substances?......... Yes No

Education

  Name of School
& Address
Major/Degree Years Completed Diploma
Degree
High
School
College

Employment Experience

Please list your work experience for the past five years, beginning with your most recent job held. If you were self-employed give firm name.

Job 1

Employer:
Address:
Phone Number:
Job Title:
Reason for Leaving:
Hourly rate/Salary:
Dates Employed:

Work Performed

Job 2

Employer:
Address:
Phone Number:
Job Title:
Reason for Leaving:
Hourly rate/Salary:
Dates Employed:

Work Performed

Job 3

Employer:
Address:
Phone Number:
Job Title:
Reason for Leaving:
Hourly rate/Salary:
Dates Employed:

Work Performed

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

References


Not including former employers or relatives.

Reference 1

Name:
Address:
Occupation:
Phone Number:

Reference 2

Name:
Address:
Occupation:
Phone Number:

Reference 3

Name:
Address:
Occupation:
Phone Number:

IMPORTANT – READ BEFORE SIGNING

In exchange for the consideration of my job application by River Country Co-op (hereinafter called “the Company”), I agree that: Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others and hereby release the Company from any liability as a result of such contact.

I also understand that the Company has a drug and alcohol policy and consent to and compliance with such policy is a condition of my employment.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Todays date:

I, acknowledge that I have read and understand the applicant statement.