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Todays Date:
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Z Gallerie is an Equal Opportunity Employer; hiring decisions are based on position availability, applicants job qualifications
and applicants schedule availability without regard to ethnicity, ancestry, religion, gender, age, disability or any other
protected class as determined by state and federal laws.
Section 1: Applicants Personal Information
Last Name:
First Name:
MI:
Present Address:
City:
State:
Primary Phone:
Yrs.
Mo.
Yrs.
Mo.
Zip:
Alternate Phone:
Previous Address:
City:
State:
Zip:
If hired, would you have a reliable means of transportation to, and from, work?
Yes
No
Yes
No
If so, where/when?
Yes
No
Desired Position:
Desired Salary:
If applying for seasonal or temporary employment, please list period you are available to work:
Can you perform all essential duties of the desired position?
Yes
Seasonal
to:
No
Please Note: Z Gallerie complies with all aspects of the Americans with Disabilities Act of 1990 (ADA) and considers reasonable
measures or accommodations to assist eligible applicants/employees perform essential duties. In addition, employment offers may be
subject to passing skill or agility tests or medical certification.
Hours Available to Work:
Mondays
Tuesdays
Any shift
Not available
List:
Any shift
Not available
List:
Wednesdays
Any shift
Not available
List:
Thursdays
Any shift
Not available
List:
Fridays
Any shift
Not available
List:
Saturdays
Sundays
Any shift
Not available
List:
Any shift
Not available
List:
Yes
No
Will you now, or in the future, require sponsorship for employment visa status (e.g., H1-B Status)?
Yes
No
Are you at least 18 years of age? (If under 18, you may be required to provide work permit prior to working)
Yes
No
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Phone Number:
Address:
Employment Dates:
Start:
Salary History:
Start:
City:
State:
Zip:
Supervisor(s):
Your Position Title:
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yy
End:
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yy
End:
Supervisors Title:
Starting:
Most Recent:
Employer 2:
Phone Number:
Address:
Employment Dates:
Start:
Salary History:
Start:
City:
State:
Zip:
Supervisor(s):
Your Position Title:
mm
yy
Yes
End:
No
mm
yy
End:
Supervisors Title:
Starting:
Most Recent:
Employer 3:
Phone Number:
Address:
Employment Dates:
Start:
Salary History:
Start:
City:
State:
Zip:
Supervisor(s):
Your Position Title:
mm
yy
Yes
End:
No
mm
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End:
Supervisors Title:
Starting:
Most Recent:
Yes
No
Section 5: References (Please provide three professional references with whom or for whom youve worked longer than a year)
Name:
Position:
Years Acquainted:
Phone Number:
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Years Completed:
Degree:
Yes
No
Have you obtained any special skills/abilities from serving in the military?
Yes
No
Do you have any experience with computer programs, cash registers, tenkey or other office tools that may prove useful to preferred position?
Yes
No
Yes
No
Yes
No
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Yes
No
Have you ever been convicted* of a felony or misdemeanor by a local, state, federal or international court?
Yes
No
Yes
No
If you answered YES to ANY of the previous two questions, please use this space to explain:
Any misdemeanor offense if probation successfully completed or otherwise discharged AND case has been judicially dismissed.
California applicants may omit convictions specified in Health & Safety code section 11361.5 (pertaining to certain marijuana offenses).
Any omission (intentional or unintentional) uncovered after an applicant is employed by the company could result in termination. If you are
unsure or have questions as to what constitutes a conviction or whether a conviction should be listed, please seek a legal opinion.
A conviction will not necessarily disqualify you from employment.
*A conviction is any plea of guilty (including Alford pleas), nolo contendere (no contest) or a verdict of guilt.
Newspaper Ad
Date:
Applications are considered for six months. If you have not been hired within six months of submitting this application and you wish to
continue to be considered for employment, please submit another application.
Revised: December 2011
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Race/Ethnicity:
American Indian/Alaskan Native
Asian
Black or African American
Hispanic or Latino
In addition, government contractors must take affirmative action to employ and advance certain
qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Readjustment Act
of 1974. Completion of the following information is voluntary and will assist us in proper placement
and reasonable accommodation.
If you wish to be identified as qualifying for such placement or accommodation, please check where
applicable:
Vietnam Era Veteran
Disabled Veteran
Sales workers
Administrative support
Operatives
Laborers and helpers
Service workers
Date:
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