EMPLOYMENT APPLICATION

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1 Date Received (mm/day/yr): / / EMPLOYMENT APPLICATION *This application is active for 60 days. Kirk Supermarket Ltd. is looking for eager individuals who possess both work ethic and an outgoing personality necessary to serve in a variety of service-oriented positions. Our team members are customer and people oriented. Complete all spaces on the form. Please indicate if a question is not applicable to you. Personal Information (Please Print) Surname: First Name: Middle: PO Box: KY_- Physical Address: District: Home Phone: Alternate/Cell Phone: Expected Rate of Pay:$ Date of Birth (mm/day/yr): / / Nationality: Immigration Status: Caymanian/Cayman Status Permanent Resident w/ Right to Work Work Permit Required Employment Rights Certificate Permanent Residency w/o Right to Work Position or Area of Interest (Please Rank your Top 3 Choices in Order of Preference) Administration Pharmacy Frozen/Dairy Produce Deli/Bakery Customer Service Maintenance Warehouse Cashier Scanning Specialty Grocery Bagger Other Area of Interest: Have you ever worked for Kirk Supermarket, Kirk Freeport, Kirk Beverage or Kirk Marine before? Yes No If yes, when, where and name of manager: Do you currently have any relatives working for Kirk Supermarket? Yes No If yes, who and where? _ Referred by: Own Initiative Department of Employment Relations Private Agency Advertisement (Explain) Other (Explain) Type of Employment Sought: Regular Temporary/ Summer Full Time Part Time Days and hours AVAILABLE for work: A.M. P.M. Monday Tuesday Wednesday Thursday Friday Saturday Sunday From To From To From To From To From To From To From To

2 If hired, when would you be able to start work? Are you willing to work holidays, variable, rotating shifts, nights and weekends? Yes No Education and Training High School Name & location Yrs completed Graduated: Yes No College Name & location Yrs completed Graduated: Yes No Type of course or degree Are you bilingual? Yes No If yes, what languages do you speak (other than English)? Technical Skills Equipment or Machinery you can operate (Please mark all that apply): Calculator Computer Cash Register Microsoft Word Microsoft Excel Pallet Jack Microsoft Outlook Microsoft Power Point Fork Lift Quickbooks Microsoft Publisher Other Other Health and Fitness Some jobs require frequent lifting, bending, stooping, pushing and pulling. Are you physically able to consistently lift, push or pull 50lbs? Yes No Are you physically able to bend and stoop frequently in order to fulfill the responsibilities of the job? Yes No Have you had any medical conditions in the past two years that have hindered you from performing your job duties? Yes No If yes, please explain Do have any mental or physical condition which may limit your ability to perform the duties of the job in which you have applied? Yes No If yes, please explain

3 Do you smoke? Yes No If yes, how much and how often? Do you take illegal drugs? Yes No Do you drink alcohol? Yes No If yes, how much and how often do you drink? Please explain Employment History Have you ever been discharged or disciplined by an employer for theft, harassment, retaliation, discrimination, disruptive behavior, or using or possessing a weapon on company premises? Yes No If yes, please explain: Have you ever been discharged or disciplined by an employer for using or possessing illegal drugs and/or substances, or for any other inappropriate conduct? Yes No If yes, please explain: Have you ever been convicted of or pled guilty, no contest, or received probation for any criminal offense, other than a minor traffic violation? Yes No If yes, please give dates and details: Tell us why you would like to work for us? What qualities, skills, attributes, special training, accomplishments and/or certifications do you posses? Work History (Include all work history and self-employment, beginning with MOST RECENT or PRESENT EMPLOYER) Employer: Address: Phone: ( ) -

4 Supervisor: May we contact your supervisor as a reference? Yes No Employer: Address: Phone: ( ) - Supervisor: May we contact your supervisor as a reference? Yes No Employer: Address: Phone: ( ) - Supervisor: May we contact your supervisor as a reference? Yes No

5 Please list three additional references (excluding relatives) we may contact with phone # s: I certify that the information contained in this application is correct to the best of my knowledge, and understand that false statements or serious omissions made in the application or during the interview process are grounds for dismissal from employment, regardless of when discovered. I understand this application does not constitute a contract and if I am hired that my employment can be terminated with cause or notice at the discretion of either myself or the company. I hereby authorize all current and former employers, educational institutions, law enforcement agencies, and/or other government agencies to provide/release information regarding my employment, education, criminal conviction record, driver s license violations and motor vehicle records that may be in their possession to Kirk Supermarket and/or its agents. I understand that, if hired, this authorization will stay in effect throughout my employment with Kirk Supermarket and/or its agents harmless for any result of a reference check. Signature Date(mm/day/yr) COMPANY USE ONLY Interviewer Name: Title: Date (mm/day/yr) HIRED Date of Offer (mm/day/yr) Starting Date (mm/day/yr) Job Title Date Accepted (mm/day/yr) Department Salary/Rate NOT HIRED Reason:

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