Russell's Western Wear, Inc. Employment Application

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1 Russell's Western Wear, Inc. Employment Application PLEASE PRINT Store Dover Lakeland Ocala Tampa Position Applied For: Desired Salary APPLICANT INFORMATION Last Name: First Name MI Date Street Address Apartment/Unit # City State Zip Home Phone Cell Phone Other Phone Address Can you perform the essential functions of the position for which you are applying? YES [ ] NO [ ] If no, please explain. (If you have any question as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer this question) When would you be available to begin work? Are you legally eligible to be employed in the United States? YES [ ] NO [ ] (Proof of identity and eligibility will be required upon employment) Are you over the age of 18 years? YES [ ] NO [ ] (If no, you may be required to provide authorization to work.) Have you ever worked for this Company before? YES [ ] NO [ ] If yes, where? When? (Give dates) Job Title: Do you have any relatives or friends who work for the Company? YES [ ] NO [ ] If yes, who and where do they work? Have you ever done any volunteer work? YES [ ] NO [ ] If yes, describe: (Omit any volunteer work which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities) Are you available to work: DAYS [ ] NIGHTS [ ] WEEKENDS [ ] FULL TIME [ ] If you cannot work full time, please explain: Days and Hours Available: (If employed, I will notify my supervisor in writing, should my availability change.)

2 Day Sunday Monday Tuesday Wednesday Thursday Friday Saturday From: To: Are you presently employed? YES [ ] NO [ ] If yes, may we contact your employer? YES [ ] NO [ ] If presently employed, why are you considering leaving? EDUCATION High School Name and Location of School Course of Study No. of Years Completed Diploma or Degree Received College Vocational or Trade School Graduate Work Have you completed any special courses, seminars and/or training that would enable you to perform the position for which you are applying? YES [ ] NO [ ] If yes, please describe: EMPLOYMENT Start with your present or most recent position Name of Employer Supervisor's Name and Title Dates Employed From Month/Day/Year To Month/Day/Year Rate of Pay Beginning Final Describe the Work Performed Name of Employer

3 Supervisor's Name and Title Dates Employed From Month/Day/Year To Month/Day/Year Rate of Pay Beginning Final Describe the Work Performed Name of Employer Supervisor's Name and Title Dates Employed From Month/Day/Year To Month/Day/Year Rate of Pay Beginning Final Describe the Work Performed Use an additional sheet of paper if more space is necessary. PERSONAL REFERENCES Give three references (not relatives or employers) Name Street City State Zip Name Street City State Zip Name Street City State Zip Occupation Occupation Occupation APPLICANTS WILL RECEIVE CONSIDERATION FOR POSITIONS, WITHOUT REGARD TO RACE, COLOR, RELIGION, AGE, SEX, EXCEPT WHERE SEX IS A BONAFIDE OCCUPATIONAL QUALIFICATION, SEXUAL ORIENTATION, MARITAL STATUS, INDIVIDUALS WITH DISABILITIES, AND EQUALLY TO DISABLED VETERANS AND VETERANS OF THE VIETNAM ERA.

4 IMPORTANT, PLEASE READ AND SIGN I understand and agree that: Any material misrepresentation or deliberate omission of a fact in my application may result in refusal of, or if employed, immediate termination from employment. Although management makes every effort to accommodate individual preference, business needs may at times make the following conditions mandatory: overtime, shift work, rotating work schedule, or work schedule other than Monday through Friday. I understand and accept these conditions of my continuing employment. It is my understanding that Accord Human Resources will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Russell's Western Wear and I release from liability any person giving or receiving such information. I agree that my employment is at will and may be terminated by Russell's Western Wear or myself at any time with or without notice or cause and without liability for wages or salary except such as may have been earned at the date of such termination. I further understand that this is an application for employment and that no employment contract is being offered, nor will any result from my employment with Russell's Western Wear. I understand that if I am employed, such employment is for no definite period of time and that Russell's Western Wear can change wages, benefits and conditions at any time. I acknowledge that any oral representation or written statements which may have been made to me to the contrary of this paragraph are expressly disavowed and may not be relied upon. Signature Date Signed:

5 NOTICE TO ALL JOB APPLICANTS AND EMPLOYEES: THIS IS A DRUG-FREE WORKPLACE. ALL OFFENDERS WILL BE DENIED EMPLOYMENT OR SUBJECT TO TERMINATION FOR USE OF OR POSSESSION OF ILLEGAL DRUGS AND/OR ALCOHOL. As a condition of employment, the applicant agrees to: Abide by the terms of this statement; Notify the employer of any criminal drug statute conviction so the Company is able to make its required notifications to any federal contracting agencies; Accept Company sanctions and participate in a drug and/or alcohol abuse assistance or rehabilitation program (if available) for violating Company policies on drug abuse. The release of an individual s drug and/or alcohol testing results and rehabilitation information is permitted only with the written consent of the individual involved. This information, however, may be released to the DOT to examine employee records and to the National Transportation Safety Board (NTSB) as part of an accident investigation and upon request or as required. APPLICANT S STATEMENT I understand that I am required to be pre-employment drug tested and consent to the urine sample collection and illegal substance testing. I understand that I may also be subject to further tests as follows: Periodic; Post-Accident; Reasonable Cause; Return to Duty; Random and follow up. Drugs to be tested for include: MARIJUANA, COCAINE, OPIATES, PHENCYCLIDINE (PCP), AMPHETAMINES AND/OR ALCOHOL OR A METABOLITE OF THESE DRUGS If offered a position with the Company and as a condition of employment, I understand that I am subject to further drug and/or alcohol testing, including random testing. A verified positive test result will disqualify me from employment with this company. By my signature below, I certify that I understand the Company s policies and procedures and have been provided with a copy of the policy. If I am employed by Russell's Western Wear, I understand and agree that I will be required to comply with the Company s policies; moreover, that if I have a verified positive drug and/or alcohol test result or refuse to submit to a drug/alcohol test, I will be removed from the covered position and will be subject to further disciplinary actions and/or termination. Type or Print Applicant s Name Applicant s Signature Date

6 Do not write below this line RESULTS Employed: YES [ ] NO [ ] If Yes, Job Title: Department Date beginning Employment Compensation $ per Interviewed by: Date:

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