* denotes a required field
PERSONAL INFORMATION
* Last Name:          * First Name:          M.I.:  
* Address:          * City:          * State:          * Zip:  
E-Mail:          * Telephone:    
ELIGIBILITY
* Are you legally eligible for employment in the United States?                                   * Are you of legal age to work?  
  (Proof of citizenship or immigration status will be required upon employment.)
* Have you ever been employed with B&R Stores?  
(including Russ's Market, Super Saver, Cash Saver, Allen’s & Apple Market)
       If so, when?        and where?  
* Do you have a relative or friend who is a current or previous employee of B&R Stores?  
       If so, please give details.       Name:         and where?  
* Have you been convicted of a crime in the last 7 years?   
(excluding parking and speeding tickets)
If applying for a position in one of our pharmacies, have you ever been convicted of a crime involving or related to pseudoephedrine (PSE) products or controlled substances?   
If YES to either question, please explain, including month/year of conviction(s):  
(A conviction will not necessarily bar you from employment, but will be considered in relation to specific job requirements.)
EMPLOYMENT DESIRED
* Position applying for:          * Location:  
* What are your salary requirements?  $. per         * Hours per week desired:  
* When are you available to start work?  
* In the following areas, please indicate in the hours you are available to work for EACH DAY:
    Check "No" in the box for any day you are not available to work.
Day Available? From To Other Times Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
- SOME WEEKEND AVAILABILITY IS REQUIRED FOR ALL POSITIONS -
Please list any changes in availability you anticipate during the next 6 months:
Please list any experiences, skills, or qualifications which will be of special benefit in the position for which you are applying:

(Applicant should not list any information that Federal and/or State law precludes obtaining in the pre-employment stage.)
Please indicate what encouraged you to apply for a position with B&R Stores (select one):
     
(i.e. RussMarket.com, Super-Saver.com, etc.) (Name of website) (Name of social_media)
                  
(If friend or relative is a current or past employee B&R
associate, please note that in eligibility section above)		 (Location of Job Fair)
EDUCATION BACKGROUND
High School: Last Grade Completed: * Diploma or G.E.D Earned:
College/Educational Institute: Years Completed:
Major/Course of Study: Degree or Certificate Earned:
Additional notes:
EMPLOYMENT BACKGROUND
* Was any employment under a different name?                  If yes, Please list:  
* Are you currently employed?                  If yes, may we contact your present employer?  
Please list your MOST RECENT employment first:
Employer:   Telephone:    
Address:   City:   State:   Zip:  
Job Title:   Supervisor:  
Job Duties:  
Rate of Pay:  $. per  Dates of Employment (Month/Year)  From:       to    
Reason for Leaving:  

Employer:   Telephone:    
Address:   City:   State:   Zip:  
Job Title:   Supervisor:  
Job Duties:  
Rate of Pay:  $. per  Dates of Employment (Month/Year)  From:       to    
Reason for Leaving:  

Employer:   Telephone:    
Address:   City:   State:   Zip:  
Job Title:   Supervisor:  
Job Duties:  
Rate of Pay:  $. per  Dates of Employment (Month/Year)  From:       to    
Reason for Leaving:  

READ STATEMENTS BELOW CAREFULLY BEFORE AGREEING
* By checking this box I certify that the information in this application is correct to the best of my knowledge and understand that should I become employed by B & R Stores, Inc. deliberate falsification of this information is grounds for dismissal.
* By checking this box I hereby authorize B & R Stores, Inc. to make any investigation of my personal history, employment record or any other area of pertinent information, and I release all parties from liability from damage. Any copy of this signed authorization shall have the full force of the original.

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