Name (Last, First, Middle) Contact Phone NumberStreet AddressCity State Zip E-mail AddressPosition(s) interested in?Salary Requirements Are you under the age o 18? Yes NoHour/Year (Circle One) I yes, state your age.Have you ever worked or Big Lots beore? Yes NoI yes, when and where?I hired, can you supply proo that you are legally entitled to work in the United States or any employer? Yes NoDo you have riends or relatives working or us? Yes NoI so, who?Can you work: Anytime Days Evenings WeekendsAre there any times or days you cannot work?Have you ever been convicted o (1) a violent crime (i.e., assault, battery, murder, etc.), (2) a retail related crime (i.e., shopliting, credit card raud,robbery, thet, burglary, etc.), or (3) drug trafcking/distribution? Yes No
Note: A “yes” response will not automatically disqualiy you rom employment, but will be considered as part o your overall job-related qualifcations or employment. You donot need to disclose any inormation regarding arrests or any criminal charges and/or convictions that have been erased, annulled, sealed and/or expunged rom your record.
I yes, please describe:
Please also provide any other inormation you would like the Company to consider about the conviction including but not limited to: the time that has elapsed since the oense, your age at the time o the oense, acts or circumstances surrounding the oense, the number o oenses or which you have been convicted, your employment history beoreand ater conviction, evidence o rehabilitation, and/or other mitigating actors. Enter N/A i you answered No and this question does not apply to you. Please use additionalpages i necessary to answer this question.
BIG LOTS EMPLOYMENT APPLICATION
This application is considered activeor ninety (90) days.
DRUG-FREE WORKPLACEAll employees are subject to drug and alcohol testingprocedures permitted under ederal and state law.
WOTC Registration #
Please complete in ink.
List names o three people (other than relatives) we may contact who have knowledge o your job-related skills.Name Telephone Contact/E-mail Contact Address/City/State Occupation
AN EQUAL OPPORTUNITY EMPLOYERBig Lots is an Equal Opportunity Employer and does not discriminate in making employment decisions based upon race,color, sex, religion, national origin, age, disability, marital status, sexual orientation, or veteran or military status.
SOS SKU# 960600043 • 05/13
Type o School Name o School Location o School Area o StudyLast Year Did You Earn aCompleted Degree or Diploma?High School 1 2 3 4 Yes NoCollege 1 2 3 4 Yes NoGraduate 1 2 3 4 Yes NoOther 1 2 3 4 Yes No
CONTINUED ON BACK
Adams, Leslie, W919-413-99991291 - D Schaub DrRaleighNC27606leslieadamsnc@gmail.comStock or cashier$7.00 ___ xxxxxxx
N/A - I do have a felony on my record that has been expunged but may still be visible to in depthsearches.
Douglas ByrdFayetteville, NCH.S. subjectsxSchenck Job CorpsPisgah Forest, NCGEDx
X919) 859-03496212 Oak Stand Cir Raleigh, NC 27606MinisterSusan Cummings919) 467-3338107 Dabney Rd Cary, NC 27511Loretta Allen-Adams919) 847-90936304 Rushingbrook DriveRaleigh, NC 27612Ret. TeacherRed Cross Vol.