HOUCHENS FOOD GROUP, INC.
APPLICATION FOR EMPLOYMENT

PERSONAL
Last Name First Middle Date

Street Address Home Telephone

City, State, Zip Business Telephone

Position Desired

Are you legally eligible for employment in the United States? When will you be available to begin work?

Other special training or skills (languages, machine operations, etc.)

EDUCATION
Course of No. of Years Did You Degree or

School Name & Location of School Study Completed Graduate Diploma

Graduate
Yes No

College
Yes No

Business/Trade
Technical Yes No

High School
Yes No

Elementary
Yes No

MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS
(Optional)

Houchens Industries, Inc. is an Equal Opportunity Employer. Houchens Industries, Inc. does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or military status.

EMPLOYMENT
1 Company Name Telephone

Address Employed-(State month and year)

From: To:

Name of Supervisor Reason for Leaving

State Job Title and Describe Your Work

2 Company Name Telephone
Address Employed-(State month and year)

From: To:

Name of Supervisor Reason for Leaving

State Job Title and Describe Your Work

3 Company Name Telephone
Address Employed-(State month and year)

From: To:

Name of Supervisor Reason for Leaving

State Job Title and Describe Your Work

4 Company Name Telephone
Address Employed-(State month and year)

From: To:

Name of Supervisor Reason for Leaving

State Job Title and Describe Your Work

MILITARY

Did you serve in the Armed Forces? If “Yes” what Branch?
Yes No

OTHER INFORMATION
Are you over 18 years of age?

Yes No
If not, employment is subject to age verification.

Have you been convicted of a crime in the past ten years? Yes No
If “Yes” describe in full. (A conviction record will not necessarily be a bar to employment)

What was your previous address? How long at your present address? _________

How long at your previous address? ________

Have you ever been previously employed by Houchens Industries, Inc. which owns and operates Houchens Markets, Jr. Food Stores, Save-A-Lot
Stores, Stewart & Richey Construction, Southern Recycling, Center of Insurance, Foodland, Piggly Wiggly, Adams and Sullivan, Buehlers Buy Low,
Scot Mkts, Shell and Pan Osten, Sonic Drive-In, Whites Fresh Foods, Subway, Scotty’s, IGA, Crossroads IGA, IGA Express, American Sun Systems,
Cohen’s Fashion Optical, Employers Risk Services, Food Giant, Four Seasons, Hilliard Lyons, Hitcents, Stephens Pipe & Steel, Tampico, T S Trucking,
Van Meter Insurance, Priceless Foods, Priceless IGA, Subway, Derby’s Pizza & Subs, Taco Del Mar, Hank’s Market and Ace Hardware? Yes No

The information provided in this Application for Employment is true, correct, and complete. If employed, any misstatement or omission of fact on this Application for Employment may result in my dismissal.

I authorize Houchens Industries, Inc. and its agents to conduct a background investigation of my personal, employment, criminal, and cred- it/financial histories as well as other matters in arriving at an employment decision. I hereby release former employers, educational institutions, law enforcement agencies, credit agencies and all other persons or legal entities from any and all liability in responding to inquiries during the investigation of my background and further release Houchens Industries,
Inc. from any and all liability in connection with the investigation of my background.

If employed, I agree to comply with all policies, procedures and conditions of Houchens Industries, Inc. relating to my employment. I understand that my employment can be terminated at any time, with or without cause, at the discretion of either Houchens Industries, Inc. or me.
I further understand and agree that the development and dissemination of policies, procedures, handbooks or other literature by Houchens
Industries, Inc. does not and will not in the future constitute or establish a contractual or other obligation to continue my employment.

Date Signature

For Employer’s Use Only

REFERENCE CHECK

Employer Person Contacted Results

1
2
3
4

TEST RESULTS

Test Administered Raw Score Rating Analysis and Comments

Interview Results

Interviewer Name and Comments

REV. 10/17

APPLICATION QUESTIONNAIRE
(Operated by Houchens Food Group)

INSTRUCTIONS: Please answer all of the questions below.

1. Can you submit verification of your eligibility to work in the United States? _____ Yes _____No
If not, your application cannot be processed. You will not be allowed to start work until you provide verification.

2. Are you at least 18 years of age? _____ Yes _____ No

3. Have you ever worked for Jr. Foods Stores, Inc., Southern Recycling, Inc., Center of Insurance, Inc.,
Stewart and Richey Construction, Inc. or in a Houchens Markets, IGA, or Save-A-Lot Food Stores or
Foodland or Piggly Wiggly or Sonic, or Shell, or Pan Osten, or Buehlers Buy Low, or Scot Markets or
Adams & Sullivan operated by Houchens Food Group?
_____ Yes _____ No

4. Do you object to working nights? _____ Yes _____ No

5. Do you object to working weekends? _____ Yes _____ No

6. Do you object to working holidays? _____ Yes _____ No

7. Do you object to selling tobacco products? _____ Yes _____ No _____ N/A

8. Have you been convicted of any felony or twice convicted of an misdemeanor involving alcohol related offenses within the last two years? _____ Yes _____ No _____ N/A

9. Have you had an alcohol license revoked within the last two years? _____ Yes _____ No _____ N/A

10. Would you be willing to take an assignment to another local store? _____ Yes _____ No

11. Do you have a telephone? _____ Yes _____ No

12. What days and hours are you available to work?

Sunday __________to__________

Monday __________to__________

Tuesday __________to__________

Wednesday __________to__________

Thursday __________to__________

Friday __________to__________

Saturday __________to__________

I understand that this Application Questionnaire is a part of the Application for Employment for the position which I am applying. I hereby certify that the above information is true and correct and that if I am employed, any false information contained on this Application Questionnaire shall be grounds for the termination of my employment.

___________________ _______________________________
Date Signature of Application

HOUCHENS FOOD GROUP, INC.
REFERENCE CHECKING AUTHORIZATION

PERMISSION TO OBTAIN INFORMATION

This document authorizes Houchens Food Group, Inc. to seek and/or verify specific information about my background. I understand that this authorization applies whether I am a current employee or a candidate for employment.

This form may be given to agencies, employers and/or schools you have attended for authorization to release information on your employment, academic history or driving record to
Houchens Food Group, Inc. Employment at Houchens Food Group, Inc. is contingent upon satisfactory references and driving records (where applicable).

By signing below, I grant permission to release information to Houchens Food Group, Inc., relating to my work, academic experience and/or driving record. I further understand that information obtained may be used by this employer in its sole discretion and without liability to determine eligibility for initial or continued employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request.

_____________________________________________________________________________________
First, Middle, Last Name (Please print or type)

___________________________ ________________________________
Driver’s License # State of Issue

If name change (through marriage or otherwise), please print former name(s) here:

_____________________________________________________________________________________

Please provide current and any previous address(es) during the past seven year:

Current: ___________________________________________________________________________

___________________________________________________________________________

Previous: ___________________________________________________________________________

___________________________________________________________________________

________________________________________________ ___________________________
Signature Date

Job Type: Part-time

Pay: $8.00 - $9.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Shift:

• 8 hour shift
• Day shift
• Night shift

Weekly day range:

• Every weekend
• Monday to Friday
• Weekends as needed
• Weekends only

Work Location: In person