Employment Application "*" indicates required fields Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment EligibilityAre you a U.S. citizen or authorized to work in the U.S. on an unrestricted basis?* Yes No Have you ever been convicted of a misdemeanor or a felony, or do you currently have any criminal cases pending?* Yes No If YES, please give the date, location, and disposition of your case.*What store are you interested in?*MansonOdeboltOnawaPercivalRed OakSioux CityBellevueBenningtonBlairColumbusFremontGothenburg ExpressGothenburg Truck PlazaGreenwoodLaurelMormon BridgeNelighNorfolkOld MarketO'NeillPenderRedmanShelbySyracuseTekamahWakefieldWaverlyYutanDakota DunesDell RapidsMitchell EastMitchell WestNorth CliffTeaWest 12thWest 12th TruckstopWest 49thPhil's Cash SaverWhat job are you interested in?* Customer Service Representative-CSR Assistant Manager Store Manager Food Service Lead Food Service Manager Area Supervisor Phil's Jobs Grocery Clerks Grocery Stockers *I understand that applicants who do not meet the minimum qualifications of the position will not be considered for the position. Only those final candidates will be contacted.Desired Pay Per Hour Week How many hours do you want to work per week? 10 20 30 40+ What times are you available to work? Mornings. 7am-3pm Evenings. 3pm-11pm Nights. 11pm—7am Weekends Please mark the days you are NOT available to work. Monday Tuesday Wednesday Thursday Friday Saturday Sunday When are you able to start? MM slash DD slash YYYY Are you 16 years of age? Yes No Are you 19 years of age? Yes No Are you 21 years of age? Yes No Positions require minimal lifting ability (approx. 40 lbs.). Do you have any injuries or physical conditions that will impair your ability to lift products? Yes No Employment HistoryJob Title PositionCompany Company NameDates Start Date End Date DutiesAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name Name Phone Number Reason for LeavingPast Employer 2Job Title PositionCompany Company NameDates Start Date End Date DutiesAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name Name Phone Number Reason for LeavingConsent* Please type your initials and email address in the following boxes. By doing so and submitting this form to Cubby's you are agreeing to the terms and conditions stated above.PLEASE READ CAREFULLY I hereby certify that the answers to the foregoing questions are true to the best of my knowledge and agree to have any of the statements checked by Cubby's unless I have indicated to the contrary. I am aware that a more detailed investigation concerning background and credit may also be conducted, if applicable to the job for which I am applying, and I hereby authorize such an investigation. I understand that employment is contingent upon satisfactory completion of reference checks and that, upon my written request, information on the nature and scope of an inquiry, if one is made, will be provided to me. I understand that nothing contained in this employment application is intended to lead to or create an employment contract between Cubby's or any subsidiary or affiliate and myself which would in any way restrict the right of the company to terminate my employment at will. I further understand and agree that the employment relationship that may result from my application will be employment-at-will, and either I or Cubby's or any subsidiary or affiliate may terminate the relationship at any time. I understand that any omission, misrepresentation or falsification can be grounds for refusal of employment. I further understand that, if employed, any false statements or misrepresentations herein or in conjunction with the application process may be cause for dismissal. I understand that any and all disputes regarding my employment with Cubby's, including any disputes relating to the termination of my employment, are subject to the Cubby's Company Policy. I also understand and agree, as a condition of employment and continued employment, to submit any such disputes in accordance with Company Policy.CommentsThis field is for validation purposes and should be left unchanged.