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Application for Employment
We are an Equal Opportunity Employer. We offer both Part Time and Full Time positions. Job includes benefits package with: Health, Dental and Eyecare, as well as Paid Vacations and Holidays. Please fill out the form below to apply.

Select Preference:
Buck   Columbia   Mountville

Position(s) Desired:
Produce Bakery Cashier Deli Gas
Meat Dairy Office Grocery

How did you learn about us?:
Advertisement Friend Walk-In
Employment Agency Relative Other  

Personal Information:
Name (First, Middle, Last):
Street:
City:
State:      Zip:   
County:
Township:
Borough:
Phone (When to call?):
Email:

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No
Have you ever filled out an application with us before? Date if yes: Yes No
Have you ever been employed with us before?
If Yes, give date:
Reason for leaving?:
Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Proof of citizenship or immigration status will be required upon employment. Yes No
On what date would you be available for work?
Indicate hours available:
Mon. Tues. Wed. Thurs. Fri. Sat. Sun.
Are you available to work:
Full Time Part Time Temporary
Is there anything that would prevent you from working evenings & weekends? Yes No
Are you currently on "lay-off" status and subject to recall? Yes No
Can you travel if a job requires it? Yes No
Have you been convicted of a felony within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.
If Yes, please explain:
Yes No

Education:
Elementary School
(Please state Name and Location of School, # of Years Attended, Subjects Studied
and if you received a Diploma/Degree)

High School
(Please state Name and Location of School, # of Years Attended, Subjects Studied
and if you received a Diploma/Degree)

Undergraduate College/University
(Please state Name and Location of School, # of Years Attended, Subjects Studied
and if you received a Diploma/Degree)

Graduate/Professional
(Please state Name and Location of School, # of Years Attended, Subjects Studied
and if you received a Diploma/Degree)

Describe any specialized training, apprenticeship, skills and extra-curricular activites:

Describe an honors you have received:

State any additional information you feel may be helpful to us in considering your application:

List professional, trade, business or civic activities and offices held.
(You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or other protected areas)

In Case of Emergency Notify:
Name:
Phone:

References:
Give name, address and telephone number of three references who are not related to you and are not previous employers.
1.
2.
3.

Have you ever had any job-related training in the United States military? If Yes, please describe:
Yes No

Have you been counseled or disciplined for attendance problems on prior jobs? Yes No

Employment Experience:
Start with your present or last job. Include any job-related military service assignments and volunteers activities. You may exclude organizations which indicate race, color, religion, gender, national origin, or other protected status.

May we request a reference from your present employer? Yes No

Employer #1
(Please indicate date started, date ended, name and address of employer, your salary, your position/work performed and your reason for leaving)

Employer #2
(Please indicate date started, date ended, name and address of employer, your salary, your position/work performed and your reason for leaving)

Employer #3
(Please indicate date started, date ended, name and address of employer, your salary, your position/work performed and your reason for leaving)

Employer #4
(Please indicate date started, date ended, name and address of employer, your salary, your position/work performed and your reason for leaving)

Special Skills and Qualifications
(Summarize special job-related skills and qualifications acquired from employment or other experience.)

Names of Relatives Employed By Us:

Applicant's Statement:
I certify that 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.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should reapply.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such a change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by the rules and regulations of the employer.

We are an Equal Opportunity Employer.

Date of Application:


Columbia (Get Directions) :: 960 Lancaster Avenue, Columbia, PA 17512 -- (717) 684-9266
Buck (Get Directions) :: 35 Friendly Drive, Quarryville, PA 17566 -- (717) 284-4147
Mountville (Get Directions) :: 3985 Columbia Ave, Columbia, PA 17512 -- (717) 285-4380
Lebanon (Get Directions) :: 1750 Quentin Road, Lebanon, PA -- (717) 270-9955

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