Name: 

Address: 

City:    State:    Zip Code: 

Telephone Number: 

Are you 16 or older?  Yes  No
Are you 18 or older?  Yes   No

List outside activities (please do not list activities that would reflect race, color, religion, sex, national origin, disability or ancestry):

Have you ever worked for the Market House before?  Yes  No
If yes, give dates employed: 

Are any of your relatives  employed by the Market House?  Yes  No
If yes, please list name(s), relationship and store location:

Give present or most recent position first.   Can we contact your current employer?  Yes  No

Company Name:  Supervisor:
Address:    Telephone: 
Employment Dates:    Position Held: 
Major Responsibilities: 
Reason for Leaving: 

Company Name:  Supervisor:
Address:    Telephone: 
Employment Dates:    Position Held: 
Major Responsibilities: 
Reason for Leaving: 

Company Name:  Supervisor:
Address:    Telephone: 
Employment Dates:    Position Held: 
Major Responsibilities: 
Reason for Leaving: 

Check the last year of college completed:  1 year 2 years 3 years 4 years More than 4 years Average Grades: 
Name & Location of School:   

Briefly describe any school activities or honors: 

Position Applying For: 
Today's Date:      Date Available To Work: 
Type of Employment Desired:  Full-time Part-time Number of Hours Available Per Week: 
Days Available to work:  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Times Available for work:  Mornings Afternoons Evenings Anytime
Do you have any commitments to another employer that might affect your employment with us?          YES NO
Are you legally eligible for employment in this country (US Citizen or alien authorized to work in the United States)?      YES NO