EmploymentApplication Form Contact InformationName(Required) First Last Date(Required) MM slash DD slash YYYY Email(Required) Phone(Required)AddressAddress(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Were you referred for this position? If so, please fill in referrer's information belowReferrer Name First Last Referrer PhoneHow did you hear about this position?Source(Required) Current Employee Career Fair Facebook Ad Indeed Other Position of Interest(Required) C-Store Casino Food Service Location of Interest(Required) Thibodaux Lockport Houma Galliano Schriever Larose Chackbay Labediville Grand Coteau Golden Meadow Raceland Highest Level of Education(Required)High SchoolSome CollegeCollege GraduateAdvanced DegreeAre you 18 years or older?(Required) Yes No Can you provide proof of legal right to work in this country?(Required) Yes No Do you speak english?(Required) Yes No Can you work weekends and or evening shifts?(Required) Yes No Are you willing to undergo a drug screen?(Required) Yes No Have you ever been disciplined or fired from a job?(Required) Yes No Can you travel, if required?(Required) Yes No Have you ever been convicted of a felony within the last 7 years?(Required) Yes No Have you worked for this company before?(Required) Yes No Are you related to an employee of this company?(Required) Yes No Do you have any special licensing or certifications?(Required) Yes No Employer 1 Employer 1 PhoneJob 1 Date Started MM slash DD slash YYYY Job 1 Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job 1 Final Date MM slash DD slash YYYY Job 1 Supervisor's Name May we contact your Supervisor as a reference? Yes No Job 1 ResponsibilitiesJob 1 Beginning Title Job 1 Ending Title Job 1 Reason Add EmployerEmployer 2 Employer 2 PhoneJob 2 Date Started MM slash DD slash YYYY Job 2 Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job 2 Final Date MM slash DD slash YYYY Job 2 Supervisor's Name May we contact your Supervisor as a reference? Yes No Job 2 ResponsibilitiesJob 2 Beginning Title Job 2 Ending Title Job 2 Reason Add EmployerEmployer 3 Employer 3 PhoneJob 3 Date Started MM slash DD slash YYYY Job 3 Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job 3 Final Date MM slash DD slash YYYY Job 3 Supervisor's Name May we contact your Supervisor as a reference? Yes No Job 3 ResponsibilitiesJob 3 Beginning Title Job 3 Ending Title Job 3 Reason Application Agreement I hereby certify that every statement I have made in this application is true and complete to the best of my knowledge. I understand that any false or incomplete answer may be grounds for not employing me or for dismissing me after I begin work. I understand that I will have to produce documentation verifying identity and employment eligibility in the U.S. I understand that I may be required to verify any and all information given on this application. I understand that this completed application is the property of GoBears Food Marts and will not be returned. I understand that GoBears Food Marts may require a drug test from me at the company’s expense and contact prior employers and other references. I understand that I must notify the Human Resources Division of any changes in my name, address, or phone number. All Applicants are subject to criminal background check. 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