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To be considered for employment with Grassroots Local Market, please fill out the following form and follow any additional instructions provided below. Only complete applications will be considered.

Name *
Name
Address *
Address
Phone *
Phone
Do you know any GLM Employees? *
Have you worked for GLM before? *
What days/times are you available to work? *
Please enter the following information: High School Name: City/State: Dates of Attendance: Did you graduate? (Yes/No) Diploma:
Please enter the following information: College/University Name: City/State: Dates of Attendance: Did you graduate? (Yes/No) Degree:
Please enter the following information: High School Name: City/State: Dates of Attendance: Did you graduate? (Yes/No) Degree:
Please enter the following information: Program Name: City/State: Dates of Attendance: Did you graduate? (Yes/No) Diploma:
Name: Relationship to you: Phone Number:
Name: Relationship to you: Phone Number:
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
Please briefly describe your related skills/experience.
(Leave blank if resume attached) Employer Name: Phone: Address: Supervisor: Job Title: Responsibilities: Dates of Employment: Reason for Leaving:
May we contact your previous supervisor for a reference?
(Leave blank if resume attached) Employer Name: Phone: Address: Supervisor: Job Title: Responsibilities: Dates of Employment: Reason for Leaving:
May we contact your previous supervisor for a reference?
(Leave blank if resume attached) Employer Name: Phone: Address: Supervisor: Job Title: Responsibilities: Dates of Employment: Reason for Leaving:
May we contact your previous supervisor for a reference?
APPLICANT STATEMENT *
I hereby certify that the information provided in this application is true and complete, and I understand that false information or significant omissions may disqualify me from consideration for employment, or may lead to dismissal if hired. I also understand that, if employed, I will be required to provide satisfactory proof of identity and legal work authorization withing three (3) days of being hired. Failure to submit such proof within the required time will result in immediate termination of employment. I authorize Grassroots Local Market (GLM) to check listed references as needed and I hold GLM harmless from any results or conclusions. I understand that GLM is an alcohol and drug-free working environment.