Express Mart Employment Application

310 S Main St, Chippewa Falls, WI 54729
715-723-2822

EMPLOYMENT APPLICATON

LOCATIONS: CHIPPEWA FALLS (BRIDGE ST) ~ (KENNEDY RD) ~ (BATEMAN) ~ (LAKE WISSOTA)
ARCADIA ~ AUGUSTA ~ BLAIR ~ BRUCE ~ COLFAX ~ ELEVA ~ FIFIELD ~ GALESVILLE ~ PHILLIPS ~ SHELL LAKE ~ STANLEY ~ THORP

Name (First, MI, Last) Street Address City, State, Zip Phone Number email Address

Have you ever worked for Express Mart before? Yes No
If Yes, give dates and Location:

Job you are applying for: Store or Location:

Hours desired per week: Expected Rate of Pay: Available Start Date:

Are you legally eligible to work in the U.S.? Yes No Are you 18 years of age or older? Yes No

Have you ever been convicted of a felony? Yes No -- If Yes, when?

Education History	Name of School	Dates Attended	Degree Received
College/Trade School
High School

Work Experience – List the past 5 years, beginning with the most recent job held.

Employer Name and Address	Start Date	End Date	Position	Rate of Pay	Reason for Leaving

Sign with your Full Name

Date