* Required

Applicant Information

* Store: --- Please select the Geissler's to which you are applying --- Agawam: 830 Suffield Street Bloomfield: 40 Tunxis Avenue East Windsor: 100 Bridge Street Granby: 9-J Bank Street Somers: 95 South Road South Windsor: 965 Sullivan Avenue Windsor: 318 Broad Street

* First Name:    * Last Name:    Age

* Street Address:    Apartment/Unit #

* City:    * State:    * Zip:

* Phone:    * Email:

Personal Questions

Are you a United States Citizen or an Alien with unrestricted authorization to work in the United States?   YES    NO

If NO, please explain.  

Have you ever worked for Geissler's in the past?   YES    NO   

If so, when?  

Have you ever been convicted or charged with a felony or misdemeanor?   YES    NO   

Please explain in details in full, including dates, details of offense(s) charged, jurisdiction and disposition of case.   

Work Amount Desired

Position Desired

Position Desired:

Alternate Position Desired:

Alternate Position Desired:

Location Desired

Location Desired:

Alternate Location Desired:

Alternate Location Desired:

Hours of Availability

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Wage Desired

Desired Wage:

Education

High School:   

Years Complete:    Did you graduate?   YES    NO    ATTENDING   

College:   

Years Complete:    Did you graduate?   YES    NO    ATTENDING   

Other:   

Years Complete:    Did you graduate?   YES    NO    ATTENDING   

Previous Employment

(Please list most recent first)

1) Company:    Job Title:   

Supervisor:    Street Address:

City:    State:    Zip:

Phone:    Ending Salary $    From:    To:

Reason For Leaving:

Responsibilities:

2) Company:    Job Title:   

Supervisor:    Street Address:

City:    State:    Zip:

Phone:    Ending Salary $    From:    To:

Reason For Leaving:

Responsibilities:

3) Company:    Job Title:   

Supervisor:    Street Address:

City:    State:    Zip:

Phone:    Ending Salary $    From:    To:

Reason For Leaving:

Responsibilities:

Personal or Business References

(Please list most recent first)

1) Full Name:    Company:   

Position:    Phone:

Relationship:   

Street Address:

City:    State:    Zip:

2) Full Name:    Company:   

Position:    Phone:

Relationship:   

Street Address:

City:    State:    Zip:

3) Full Name:    Company:   

Position:    Phone:

Relationship:   

Street Address:

City:    State:    Zip:

Special Skills and Qualifications

Describe any special skills or qualifications for this position:   

Disclaimer and Signature

I CERTIFY that my answers are true and complete to the best of my knowledge. I authorize Geisslers of Bloomfield to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in immediate termination. I understand that I am required to abide by all rules, regulations and policies of Geisslers of Bloomfield.

* Signature (type name):    * Date: