APPLICATION FOR EMPLOYMENT

KELLER’S APPLICATION FOR EMPLOYMENT

NOTICE TO APPLICANTS FOR EMPLOYMENT: You must be at least 18 years of age to apply for a position with Keller’s Farm Stores. Be advised that all statements and responses made on your application for employment will be verified by a background investigation. If any statement made by an applicant is found to be false or misleading, consideration of the application will be discontinued and employment denied. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

I. PLEASE PRINT:

Last Name______________________________ First Name_____________________________

Middle Name _____________________

Address_______________________________________________________________________

Phone Number (home)_________________________(cell)_____________________________

Social Security Number (Voluntary) ________________________________________________

Position(s) Applied For___________________________________________________________

Date of Application ____/____/______

How Did You Learn About Us? ___________________________________________________

II. PLEASE INDICATE THE MOST APPROPRIATE ANSWER. ELABORATE

WHERE NECESSARY:

1. Are you over 18 years of age? .......................................................................................Yes / No

2. Have you filed an application with us before? ..............................................................Yes / No

If yes, give date ____/____/______

3. Have you been employed with us before? .....................................................................Yes / No

If yes, give dates ____/____/______ - ____/____/______

4. Do any of your friends or relatives work here? .............................................................Yes / No

If yes, please list__________________________________________________________

5. Are you currently employed? ........................................................................................Yes / No

6. May we contact your current employer? .......................................................................Yes / No

7. Are you prevented from lawfully becoming employed in this country because of Visa or

Immigration Status? Proof of citizenship or immigration status will be required upon

employment......................................................................................................................Yes / No

8. Are you currently on “lay-off” status and subject to recall? .........................................Yes / No

9. Date available for work ____/____/______

10. What is your expected rate of pay? ______________________________________________

11. Are you available to work:

____ Full-time

____ Part-time (please indicate: Mornings Afternoons Evenings)

____ Temporary (please indicate dates available ____/____/______ - ____/____/______)

12. At which location are you available to work? (Please circle one or both)

2912 Eubank at Candelaria 6100HCoors and Montano

13. Can you work on Saturday? ............Yes / No Can you work on Sunday? ............Yes / No

14. How many days did you miss from work in the last year (do not count vacations)?_____days

15. If hired for this job, what do you believe are your chances of becoming an outstanding

employee? Please circle:

Excellent Very Good Good Fair Poor

16. How would your previous supervisors rate your work performance? It would be:

Excellent Very Good Good Fair Poor

17. In the past five years, have you been fired or asked to resign from a job? ..................Yes / No If yes, please explain ______________________________________________________ ________________________________________________________________________

18. Did you ever leave a job because you might have been fired if you had not quit?......Yes / No

If yes, please explain ______________________________________________________ ________________________________________________________________________

19. I think the percentage of employees who steal from their employers is: Please circle:

Over 50% 50% 35% 25% 15% 10% 5% 1%

20. I rate my own honesty as follows: Please circle:

a. Far above average b. Above average c. Slightly above average d. Average

e. Slightly below average f. Below average g. Far below average

21. If necessary for employment, would you take a drug test?............................................Yes/No

22. If hired, how long do you plan to work for this company? ____________________________

23. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? Do not answer this question unless you have been informed about the requirements of the job for which you are applying..........................................................................................................Yes/No

III. PRACTICAL APPLICATION:

1. If you are filling an order for ten pounds of T-Bones, and you have 6.39 pounds, how many more pounds do you need?______________________

2. If a customer buys twelve items at $1.79 each, what will the total cost be?_______________

3. If a customer buys chickens that total $9.43, spare ribs that total $8.92, and liver that totals $3.62, what will the total cost (before tax) be?____________________

4. The standard serving on boneless beef is a 1/2 pound per person. If a customer wants to serve a boneless beef roast to 18 people, approximately how many pounds should the roast they purchase weigh?______________________

IV. REFERENCES:

______________________________________________________________________________

Name Relationship Phone Number

______________________________________________________________________________

Name Relationship Phone Number

______________________________________________________________________________

Name Relationship Phone Number

V. EDUCATION:

What is the highest school graduation level you have attained? ___________________________

Name and Address of School______________________________________________________

Course of Study_________________________________________________________________

VI. EMPLOYMENT EXPERIENCE:

A) Please describe any specialized training, apprenticeships, military training, extra curricular activities, equipment operated, job related skills and qualifications etc. that you feel may be helpful to us in considering your application.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B) Start with your present or last job. Include any job-related military service assignment and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, or other protected status.

1. Employer ___________________________________________________________________

Address ______________________________________________________________________

Telephone Number(s) ___________________________________________________________

Job Title ______________________________________________________________________

Supervisor ____________________________________________________________________

Reason for Leaving______________________________________________________________

Work Performed: _______________________________________________________________

C) Which of your past jobs did you like the most? Why? ____________________________

______________________________________________________________________________

D) Which of your past jobs did you like the least? Why? ____________________________

______________________________________________________________________________

VII. APPLICANT'S STATEMENT:

I certify that answers given herein are true and complete. In connection with my application for employment with Keller's, I understand that an investigative report may be requested that will include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance and experience, along with reasons for termination of past employment from previous employers. Further, I understand that information may be requested concerning my motor vehicle registration history and criminal history from various states, private and insurance sources along with other public records available.

I voluntarily and knowingly authorize any present or past employer or supervisor; institution of learning; administrator, law enforcement agency, local agency, state agency, Federal agency; private business; military branch or the National Personnel Records Center, personal references; and/or other persons to give records or information they may have concerning information requested as part of the background investigation. I voluntarily and knowingly unconditionally release any named or unnamed informant from all liability resulting from the furnishing of this information. A photocopy of this Designation and Authorization for Release and Re-disclosure of Information shall be considered by the recipient to be a signed original, as long as it is transmitted to the recipient by Keller's or HSC and is received within one year of its date.

If I am denied employment, either wholly or partly, because of information contained in resulting reports, a disclosure will be made to me of the name and address of the consumer reporting agency making such report. If the report contains information about me that is a matter of public record, such as arrests, indictments or convictions, I may also be informed of the name and address of any person to whom the information is reported.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct. I hereby understand and acknowledge that if hired for a position there will be no guarantee of the number of hours scheduled per week. It is further understood that working high volume sales days is a condition of employment.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer.

I have read the above notice, understand what it means, and agree to the terms.

______________________________________________________________________________

Signature of Applicant Date