Safeway Job Application Form

Safeway Job Application.pdf This form can let anyone submit their information for employment at any Safeway location in the United States.

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1/2008

AN EQUAL OPPORTUNITY EMPLOYER

The Safeway policy is to provide employment, training, compensation, promotion and other conditions of employment without regard to race, color,

religion, sexual orientation, national origin, sex, age, disability, veteran or any other legally protected status. Applicants must reapply at least once

every two months to remain under consideration for employment.

PERSONAL INFORMATION

NAME

First Middle Initial Last

TEL. NO. ( )

OTHER NAMES USED FOR EMPLOYMENT OR EDUCATION (if any)

ADDRESS

Street/Apt. # City State ZIP County

SOCIAL

SECURITY NO.

FOR WHAT POSITION(S) ARE YOU APPLYING? FULL-TIME PART-TIME EITHER

PREFERRED FACILITY/STORE?

ARE YOU UNDER THE AGE OF 18? YES NO IF UNDER 18, STATE YOUR AGE

ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? YES NO

HAVE YOU WORKED FOR SAFEWAY OR ONE OF ITS AFFILIATED COMPANIES LISTED AT THE TOP OF THIS APPLICATION? YES NO

WHEN? WHERE?

POSITION HELD? REASON FOR LEAVING?

LIST THE NAMES OF RELATIVES EMPLOYED BY ANY OF THE SAFEWAY COMPANIES AND THEIR WORK LOCATION NONE

DATE AVAILABLE FOR WORK TOTAL HOURS AVAILABLE PER WEEK

(You may list time needed for religious practices/observances as “available” time.) The majority of retail store shifts are afternoons, evenings and weekends.

SUN MON TUES WED THURS FRI SAT

Earliest Time

Latest Time

NAME RELATIONSHIP WORK LOCATION

1.)

2.)

3.)

YES NO

FOR APPLICANTS OUTSIDE OF HAWAII:

HAVE YOU BEEN CONVICTED OF A CRIME WITHIN THE LAST TEN (10) YEARS (other than a minor traffic violation)?

Hawaii applicants do NOT answer this question.

IF YES, STATE THE DATE, LOCATION, NATURE AND DISPOSITION OF THE OFFENSE:

(A “Yes” answer will not necessarily disqualify you from employment.)

*FOR HAWAII APPLICANTS: If you are made a conditional offer of employment, you will be asked to provide information regarding criminal convictions prior to hiring.

To learn more & join the Safeway team visit Safeway.com

APPLICATION FOR EMPLOYMENT

(Non-California Applicants ONLY)

1/2008

EDUCATION

NAME & ADDRESS OF SCHOOLS ATTENDED FROM

mo/yr

TO

mo/yr

CIRCLE HIGHEST

GRADE/LEVEL COMPLETED DEGREE/MAJOR

HIGH SCHOOL

COLLEGE

GRADUATE

OTHER

RECORD OF U.S.A. MILITARY AND RESERVE STATUS

Service Dates

FROM mo yr TO mo yr Branch Reserve Unit Meeting Dates

Summarize skills, training or qualifications:

PROFESSIONAL/PERSONAL REFERENCES

NAME ADDRESS PHONE NUMBER OCCUPATION

1.)

2.)

EMPLOYMENT HISTORY

List each job held during the last seven (7) years with a minimum of three (3) employers. Start with your present or last job. Also, include any periods

of unemployment, military service, and volunteer and/or part-time work experience. If necessary, use an additional sheet to include related work

history beyond seven (7) years.

Applicant Signature Date Interviewer’s Signature Date

Certification: I certify that the information I provided on this application is true and correct to the best of my knowledge, and I agree to have this

information checked by the Company. I authorize the references listed to provide the Company with information about my previous employment

and any other information they may have. I release all parties and persons, including the Company, from any and all liability for any damages for

providing this information, consistent with state and federal law.

At-will employment: I understand that nothing in this application is intended to be, or is, an offer of employment or a promise of continued

employment. I understand that if I become employed by the Company, my employment is for no specific term. I further understand that, except

for any periods of time that I am employed in a position covered by an express written agreement that provides otherwise, my employment with

the Company may be terminated at any time, with or without cause and/or notice, at the will of either me or the Company. I further understand

that no Company representative has any authority to enter into any agreement with me different or contrary to the foregoing.

Eligibility verification: I understand that any false statement or omission on this application may prevent me from receiving an offer of employment,

may result in a withdrawal of an employment offer, or may result in my discharge from employment if I am already employed at the time the false

statement or omission is discovered.

I understand that any offer of employment is conditioned on satisfactory proof of my identity, that I am of legal age, and that I have legal authorization to work

in the United States. I also understand that this may include the Company’s receipt of satisfactory responses to reference requests, my passing of any required drug

screening test, satisfactory completion of a background check, if applicable, and satisfactory completion of a post-offer medical examination, if applicable.

FROM

TO

FROM

TO

FROM

TO

FROM

TO

FROM

TO

START

FINAL

START

FINAL

START

FINAL

START

FINAL

START

FINAL

READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE THE APPLICATION

EMPLOYMENT

DATES (mo/yrs)

COMPANY AND

MAILING ADDRESS

SUPERVISOR’S

NAME/PHONE

SALARY YOUR JOB TITLE SPECIFIC JOB DUTIES

REASON FOR

LEAVING

Please initial each of the following paragraphs:

9 10 11 12

1 2 3 4

1 2 3 4

1 2 3 4

To learn more & join the Safeway team visit Safeway.com

APPLICATION FOR EMPLOYMENT

(Non-California Applicants ONLY)

Have you ever been fired from a job or given an opportunity to resign? Yes No

If yes, Explain:

1/2008

APPLICATION INFORMATION

To be completed by Applicant

NAME (Required)

First Middle Initial Last

Source Code

Walk-in

Newspaper Advertisement

Employee Referral

Employment Agency

Female/Minority Group Referral

Community/Vocational Rehab Org

High School/College Referral

Job Fair/Recruiting Event

Internal Postings

Job Postings

Other (Explain) _______________

____________________________

Internal Employee Application

TO BE COMPLETED BY HIRING PERSONNEL ONLY

Application Date

Month Day Year

Jan

Feb

Mar

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Apr

0

1

2

3

0

1

2

3

4

5

6

7

8

9

2005

2006

2007

2008

2009

2010

Job Group Codes

1B Assistant Store Managers

1C Department Managers

1D Head Clerks

1E Pharmacy Manager

1F Supply Manager/Supervisor

1G Backstage Manager

1H Distribution Manager

2A Pharmacist

2B Professionals

3A Technician

4A Food Clerks: Jny/App/Produce

4B Service Departments

4C Courtesy/Helper Clerks

5A Senior Clerical

5B Clerical

6A Crafts, Skilled

7A Operators, Semi-Skilled

8A Laborers, Unskilled

9A Service Workers

Disposition Codes

A = No position available within the last 60 days

B = More qualified applicants available

C = Unavailable to work required hours

D = Available type of work was not acceptable

E = Unable to contact/unavailable for interview

F = Wage not acceptable

G = Did not meet post-offer policy requirements

H = Declined job offer

I = Did not show up for interview

J = Ineligible for rehire

K = Did not pass pre-employment test

L = Hired

M = Other

Interview Date

Month Day Year

Jan

Feb

Mar

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Apr

0

1

2

3

0

1

2

3

4

5

6

7

8

9

2005

2006

2007

2008

2009

2010

(mark appropriate boxes)

To learn more & join the Safeway team visit Safeway.com

APPLICATION FOR EMPLOYMENT

(Non-California Applicants ONLY)

Race/Ethnic Group

SELECT ONLY ONE

American Indian/Alaskan Native

Native Hawaiian/

Other Pacific Islander

Black/African American

Asian

Hispanic/Latino

White

Two or More Races

Decline Disclosure

Gender

Male

Female

Decline Disclosure

1/2008

NOTICE AND CONSENT CONCERNING CONSUMER REPORTS

AND INVESTIGATIVE CONSUMER REPORTS

This form, which you should read carefully before signing, has been provided to you because Safeway Inc. (“the Company”) may

request consumer reports or investigative consumer reports from USIS Commercial Services, Inc. (“USIS”) in connection with your

application for employment or, if you are or become employed by the Company, during the course of your employment with the

Company. Such reports may be requested for purposes of evaluating your suitability for employment, promotion, reassignment,

retention or other employment-related purposes.

The types of reports that the Company may request from USIS include, but are not limited to: credit reports, criminal records checks,

court records checks, driving records, and/or summaries of educational, employment records and histories, and investigative consumer

reports (reports with information regarding your character, general reputation, personal characteristics or mode of living). The

information contained in these reports may be obtained by USIS from public record sources, educational institutions, USIS clients, or

through personal interviews with your co-workers, neighbors, friends, associates, current or former employers, or other people you

know. You have the right to request additional disclosures of the nature and scope of the investigation by USIS and a statement of

your rights. To receive this information or to inspect any files concerning such a report or to determine if a report on you has been

requested, you may contact USIS by mail at 4500 S. 129th East Avenue, Suite 200, Tulsa, Oklahoma 74153, by phone at (800) 331-9175

or by fax at (918) 627-6162.

If any adverse decision with regard to your application for employment with the Company or, if you are hired, during the cours of your

employment, is based in whole or part on the information contained in a consumer report or an investigative consumer report, you

will be notified as to the basis for the decision and given a copy of the report, as well as a summary of your applicable rights.

CONSENT TO CONSUMER REPORTS AND INVESTIGATIVE CONSUMER REPORTS

I have carefully read and understand the Notice Concerning Consumer Reports and Investigative Consumer Reports and this Consent

to Consumer Reports and Investigative Consumer Reports (“Consent”) and, by my signature below, I authorize USIS to release

consumer reports and/or investigative consumer reports, as described above, to the Company: (1) in conjunction with my application

for employment and (2) during the entire course of my employment. I further understand that any and all information contained in

my job application or otherwise disclosed to the Company by me before or during my employment may be utilized for the purpose of

obtaining the consumer reports or investigative consumer reports requested by the Company, and I confirm that all such information

provided in connection with my job application is true and correct. I also agree that a facsimile, photocopy or electronic copy of this

form may be used in lieu of the original.

I also authorize the following entities to disclose to USIS and its agents all information about or concerning me, including, but not

limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other

federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records

agencies; all other private and public sector repositories of information; and, any other person, organization or agency with any

information about or concerning me. The information that can be disclosed to USIS and its agents includes, but is not limited to,

information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history,

drug test results, military service, professional credentials, and all other information requested by USIS or its agents.

NOTICE TO WASHINGTON STATE APPLICANTS OR EMPLOYEES

If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a

right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the right to

ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

NOTICE TO WASHINGTON STATE APPLICANTS OR EMPLOYEES

If you submit a request in writing to USIS within a reasonable amount of time after you review and sign this document, you have a

right to obtain from USIS complete and accurate disclosure of the nature and scope of the consumer report ordered and the right to

ask USIS for a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Name of Applicant (Print)

Applicant or Employee Signature

Date

, 20

Social Security Number

Street Address

City, State and ZIP Code