Application

Personal Information

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Email

Telephone

Elegibility

Are you legally eligible for employment in the United States?

Yes No

Are you of legal age to work?

Yes No

(Proof of citizenship or immigration status will be required upon employment.)

Have you ever been employed with B&R Stores? (including Russ's Market, Super Saver, Save Best & Apple Market)

Yes No

If so, when?

and where?

Do you have a relative or friend who is a current or previous employee of B&R Stores?

Yes No

If so, please give details

and where?

Have you been convicted of a crime in the last 7 years? (excluding parking and speeding tickets)

Yes No

If applying for a position in one of our pharmacies, have you ever been convicted of a crime involving or related to pseudoephedrine (PSE) products or controlled substances?

Yes No

If yes to either question, please explain: (A conviction will not necessarily bar you from employment, but will be considered in relation to specific job requirements.)

Employment Desired

Position applying for

Location

What are your salary requirements?

Per

Hours per week desired

When are you available to start work?

In the following areas, please indicate in the hours you are available to work for EACH DAY:
Check "No" in the box for any day you are not available to work.

Monday

Available?

yes no

From

To

Other times avaiable?

Tuesday

Available?

yes no

From

To

Other times avaiable?

Wednesday

Available?

yes no

From

To

Other times avaiable?

Thursday

Available?

yes no

From

To

Other times avaiable?

Friday

Available?

yes no

From

To

Other times avaiable?

Saturday

Available?

yes no

From

To

Other times avaiable?

Sunday

Available?

yes no

From

To

Other times avaiable?

- SOME WEEKEND AVAILABLITY IS REQUIRED FOR ALL POSITIONS -

Please list any changes in availability you anticipate during the next 6 months:

Please list any experiences, skills, or qualifications which will be of special benefit in the position for which you are applying: (Applicant should not list any information that Federal and/or State law precludes obtaining in the pre-employment stage.)

Please indicate what encouraged you to apply for a position with B&R Stores:
(If friend or relative is a current or past employee B&R associate, please note that in eligibility section above)

Please give us the name of Website, Newpaper, Job Fair, or Store

Education Background

High School

Last grade completed

Diploma or G.E.D. Earned

College/Educational Institute

Major/Course of Study

Years Completed

Diploma or Certificate Earned

Additional Notes

Employment Background

Was any employment under a different name?

If yes, please list

Are you currently employed?

If yes, may we contact your present employer?

Please list your MOST RECENT employment first

Employer #1

Telephone

Address

City

State

Zip

Job Title

Supervisor's Name

Job Duties

Rate of Pay

Per

Dates of Employment From

To

Reason for leaving

Employer #2

Telephone

Address

City

State

Zip

Job Title

Supervisor's Name

Job Duties

Rate of Pay

Per

Dates of Employment From

To

Reason for leaving

Employer #3

Telephone

Address

City

State

Zip

Job Title

Supervisor's Name

Job Duties

Rate of Pay

Per

Dates of Employment From

To

Reason for leaving

READ STATEMENTS BELOW CAREFULLY BEFORE AGREEING

By checking this box I certify that the information in this application is correct to the best of my knowledge and understand that should I become employed by B & R Stores, Inc. deliberate falsification of this information is grounds for dismissal.

By checking this box I hereby authorize B & R Stores, Inc. to make any investigation of my personal history, employment record or any other area of pertinent information, and I release all parties from liability from damage. Any copy of this signed authorization shall have the full force of the original.