APPLICATION FOR EMPLOYMENT
We are pleased that you are interested in employment with Bi-Mart Corporation. To be considered for possible employment, applications must be
accompanied by a signed and dated summary of the position for which you are applying. Please review the position summary thoroughly before
completing this application. This Application For Employment will be considered “active” for one (1) month from the date signed.
Bi-Mart is strongly committed to providing a safe and productive work environment for its employees and to providing excellent service to its customers.
As a part of the hiring process, all applicants considered for employment are required to submit to and pass a drug test.
 PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR ABILITY.
 PRINT LEGIBLY WITH AN INK PEN OR TYPE THE ANSWERS
 DO NOT LEAVE BLANK SPACES—PRINT N/A (NOT APPLICABLE) WHEN NECESSARY.
AREA OF INTEREST & AVAILABILITY
POSITION APPLIED FOR: ______________________________________________________________PREFERRED LOCATION_________________________________________
FULL TIME 
PART-TIME 
TEMPORARY/SEASONAL 
AVAILABLE HOURS: MON: ____________ TUE: ____________ WED: ____________ THU: ____________ FRI: ____________ SAT: ____________ SUN: _________
(i.e. 7am - 4pm; noon-8 pm; ANY)
PAY EXPECTED:
$ _____________________________ If “Negotiable”, enter range: _____________________________ Date you can start: __________________________
HOW DID YOU FIND OUT
ABOUT THIS OPENING? NEWSPAPER 
INTERNET
SCHOOL  STORE ANNOUNCEMENT COMPANY RECRUITER 
 (Specify which site): ______________________________ OTHER  (Explain): _______________________________________________
HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH BI-MART CORPORATION? NO 
YES 
When? _______________________________ For what position? _______________________________ What location? _____________________________
PERSONAL INFORMATION
FULL NAME:
____________________________________________________________________________________________ SS#: ______________________________
(LAST)
(FIRST)
(MIDDLE)
ALL OTHER LAST NAMES USED: ______________________________________________________ NICKNAME(S): __________________________________________________
CONTACT
INFORMATION:
HOME PHONE #: __________________________________________ WORK PHONE #: ______________________________________________________
CELL PHONE #: ___________________________________________ E-MAIL ADDRESS: _____________________________________________________
CURRENT
MAILING ADDRESS:
_____________________________________________________________________________________________
(NO. & STREET)
CURRENT
STREET ADDRESS:
(CITY)
(ZIP CODE)
_____________________________________________________________________________________________ HOW LONG? ____________________
(NO. & STREET)
PREVIOUS
STREET ADDRESS:
(STATE)
(CITY)
(STATE)
(ZIP CODE)
(IF LESS THAN 3 YRS. PLEASE
PROVIDE YOUR PREVIOUS ADDRESS)
_____________________________________________________________________________________________ HOW LONG? ____________________
(NO. & STREET)
(CITY)
AGE INFORMATION: ARE YOU 18 OR OLDER? NO 
DRIVER’S LICENSE
OR STATE ISSUED ID: NO 
YES 
(STATE)
(ZIP CODE)
IF HIRED, CAN YOU PROVIDE PROOF OF YOUR AGE? NO 
YES 
YES  STATE: ________ NUMBER: _________________________________________ EXP. DATE: _____________________
(MM/DD/YYYY)
CITIZENSHIP:
CAN YOU PROVIDE PROOF OF YOUR LEGAL RIGHT TO REMAIN AND WORK IN THE U.S.A.?
PREVIOUSLY
EMPLOYED
BY BI-MART?:
NO 
NO 
YES 
YES  IF YES, WHAT LOCATION/DEPT.: _________________________________________________________________________
NAME OF
DATES
JOB TITLE: _______________________________ SUPERVISOR: _______________________________ EMPLOYED: ___________________________
RELATIVE/FRIENDS NO 
CURRENTLY EMPLOYED
YES  IF YES, NAME: ______________________________________________ RELATIONSHIP: ___________________________
WHERE DOES HE/SHE WORK? ____________________________________ WHAT POSITION? ____________________________________
Revised 10/2015
PAGE 1 OF 4
EDUCATION
WHAT NAME(S) ARE
RECORDS UNDER?
SCHOOLS ATTENDED
LAST HIGH SCHOOL:
(City)
CIRCLE HIGHEST
GRADE COMPLETED
7
(State)
8 9 10 11 12
CHECK ALL THAT APPLY
 Diploma
 GED
 NCRC: ______________
(Specify Certification Level)
COLLEGE/UNIVERSITY OR TECHNICAL/TRADE OR MILITARY SCHOOLS ATTENDED:
(Include City and State)
WHAT NAME(S) ARE
RECORDS UNDER?
DEGREE OR
CREDITS RECEIVED
MAJOR(S)
NAME:
(City)
(State)
NAME:
(City)
(State)
NAME:
(City)
(State)
LIST ANY CURRENT LICENSES/CERTIFICATES/REGISTRATIONS: ______________________________________________________________________________________________
Are you currently attending school? NO 
YES 
If YES, what hours/days are you attending: _______________________________________________________________
WORK EXPERIENCE
LIST YOUR MOST RECENT JOB FIRST
PROVIDE A COMPLETE RECORD OF ALL EMPLOYMENT IN THE LAST 15 YEARS
PROVIDE REASONS FOR PERIODS OF UNEMPLOYMENT IN EXCESS OF THIRTY (30) DAYS.
#1
DATE EMPLOYED
(Month & Year)
MO
YR
/
COMPANY/ORGANIZATION
(Complete Name & Address)
JOB TITLE/DUTIES PERFORMED
AT START OF EMPLOYMENT
JOB TITLE/DUTIES PERFORMED
AT END OF EMPLOYMENT
______________________________________
MO
(FROM)
YR
(TO)
(Name)
______________________________________
TYPE OF BUSINESS?
(Street address)
______________________________________
(City)
(State)
AVG. HRS.
WORKED
PER WEEK
HOW WAS POSITION
OBTAINED?
(Zip)
SALARY
AT
START
UPON
LEAVING
NUMBER OF
PEOPLE YOU
SUPERVISED
REASON FOR LEAVING OR LOOKING
TO LEAVE (BE SPECIFIC)
IMMEDIATE SUPERVISOR
NAME: _______________________________________
TITLE: _______________________________________
PHONE #: ____________________________________
MAY WE CONTACT NOW?
#2
DATE EMPLOYED
(Month & Year)
MO
YR
(FROM)
/
COMPANY/ORGANIZATION
(Complete Name & Address)
JOB TITLE/DUTIES PERFORMED
AT START OF EMPLOYMENT
YES 
NO 
JOB TITLE/DUTIES PERFORMED
AT END OF EMPLOYMENT
______________________________________
MO
YR
(TO)
TYPE OF BUSINESS?
(Name)
______________________________________
(Street address)
______________________________________
(City)
HOW WAS POSITION
OBTAINED?
(State)
AVG. HRS.
WORKED
PER WEEK
(Zip)
SALARY
AT
START
UPON
LEAVING
NUMBER OF
PEOPLE YOU
SUPERVISED
REASON FOR LEAVING OR LOOKING
TO LEAVE (BE SPECIFIC)
IMMEDIATE SUPERVISOR
NAME: _______________________________________
TITLE: _______________________________________
PHONE #: _____________________________________
MAY WE CONTACT NOW?
YES 
NO 
PAGE 2 OF 4
WORK EXPERIENCE CONTINUED
#3
DATE EMPLOYED
(Month & Year)
MO
YR
/
COMPANY/ORGANIZATION
(Complete Name & Address)
JOB TITLE/DUTIES PERFORMED
AT START OF EMPLOYMENT
JOB TITLE/DUTIES PERFORMED
AT END OF EMPLOYMENT
______________________________________
MO
(FROM)
YR
(TO)
(Name)
______________________________________
TYPE OF BUSINESS?
(Street address)
______________________________________
(City)
(State)
AVG. HRS.
WORKED
PER WEEK
HOW WAS POSITION
OBTAINED?
(Zip)
SALARY
AT
START
UPON
LEAVING
NUMBER OF
PEOPLE YOU
SUPERVISED
REASON FOR LEAVING OR LOOKING
TO LEAVE (BE SPECIFIC)
IMMEDIATE SUPERVISOR
NAME: _______________________________________
TITLE: _______________________________________
PHONE #: ____________________________________
MAY WE CONTACT NOW?
#4
DATE EMPLOYED
(Month & Year)
MO
YR
/
COMPANY/ORGANIZATION
(Complete Name & Address)
JOB TITLE/DUTIES PERFORMED
AT START OF EMPLOYMENT
YES 
NO 
JOB TITLE/DUTIES PERFORMED
AT END OF EMPLOYMENT
______________________________________
MO
(FROM)
YR
(TO)
(Name)
______________________________________
TYPE OF BUSINESS?
(Street address)
______________________________________
(City)
(State)
AVG. HRS.
WORKED
PER WEEK
HOW WAS POSITION
OBTAINED?
(Zip)
SALARY
AT
START
UPON
LEAVING
NUMBER OF
PEOPLE YOU
SUPERVISED
REASON FOR LEAVING OR LOOKING
TO LEAVE (BE SPECIFIC)
IMMEDIATE SUPERVISOR
NAME: _______________________________________
TITLE: _______________________________________
PHONE #: ____________________________________
MAY WE CONTACT NOW?
#5
DATE EMPLOYED
(Month & Year)
MO
YR
(FROM)
/
COMPANY/ORGANIZATION
(Complete Name & Address)
JOB TITLE/DUTIES PERFORMED
AT START OF EMPLOYMENT
YES 
NO 
JOB TITLE/DUTIES PERFORMED
AT END OF EMPLOYMENT
______________________________________
MO
YR
(TO)
TYPE OF BUSINESS?
(Name)
______________________________________
(Street address)
______________________________________
(City)
HOW WAS POSITION
OBTAINED?
(State)
AVG. HRS.
WORKED
PER WEEK
(Zip)
SALARY
AT
START
UPON
LEAVING
NUMBER OF
PEOPLE YOU
SUPERVISED
REASON FOR LEAVING OR LOOKING
TO LEAVE (BE SPECIFIC)
IMMEDIATE SUPERVISOR
NAME: _______________________________________
TITLE: _______________________________________
PHONE #: ____________________________________
MAY WE CONTACT NOW?
YES 
NO 
APPLICANTS MUST PROVIDE A COMPLETE RECORD OF ALL EMPLOYMENT IN THE LAST 15 YEARS
- USE ADDITIONAL SHEETS IF NEEDED PAGE 3 OF 4
SKILLS AND INTERESTS
List outside activities while in school (athletics, clubs, offices held):
Personal aptitudes/interests:
List technical/occupational skills (include level of proficiency):
Career aims/goals:
BACKGROUND
TERMINATION:
Have you ever been discharged or asked to resign from a job? NO 
YES 
If yes, please explain:________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
COMMENTS
MAKE ANY ADDITIONAL COMMENTS YOU WISH IN THE SPACE BELOW:
ACCEPTANCE
It is the policy of Bi-Mart to recruit, employ, transfer, develop and promote individuals without regard to race, national origin, ancestry,
religion, age, sex, gender identity, marital status, disability, or any other protected class as provided by law.
1. I declare that all statements and answers herein are true and complete, and understand that any untruth, misleading answer,
omission, concealment, or failure to answer questions fully, completely, and accurately are grounds for termination of my
employment.
2. I authorize Bi-Mart at any time following an interview to investigate my references, to communicate with former employers
concerning same, and to make an independent investigation of my character, conduct, employment, criminal, financial, and driver’s
records.
3. I agree that Bi-Mart, my previous employers and any other sources used in this investigation shall not be held liable in any respect
if an employment offer is not tendered, is withdrawn, or my employment is terminated due to false statements or answers in this
application or any other information gained in this investigation.
4. I agree to return all company records, equipment, and uniforms upon termination of employment.
5. I understand that this application for employment is not a contract of employment. All employment at Bi-Mart is strictly
“Employment At Will” which means that an employee may voluntarily end his/her employment at any time with or without notice for
any reason, and the company maintains the same right. This relationship cannot be modified by anyone other than in writing by
the Director of Human Resources or the President of the Company. Any representations by any other person contrary to the
“Employment At Will” Doctrine, either verbal or written, shall not be relied upon by any employee.
_____________________________________________
PRINT NAME
_____________________________________________________ __________
SIGNATURE
DATE
BI-MART CORPORATION
220 S. SENECA RD. • P.O. BOX 2310 • EUGENE, OREGON 97402
PHONE (541) 344-0681 • FAX (800) 333-8967
PAGE 4 OF 4
LOSS PREVENTION OFFICER
Position Overview
The Loss Prevention Officer position provides specialized loss prevention services to an assigned group of retail
stores. Primary job responsibility is the observation and apprehension of individuals engaged in retail theft
activity utilizing the fundamental elements required for a lawful arrest. Loss Prevention Officers are also
responsible for assisting with the set up, routine maintenance, and repair of in-store security systems designed to
protect company assets and merchandise
•
Reports to: Loss Prevention District Manager (primary); Corporate Loss Prevention Manager
(secondary)
•
Coordinates with: Loss Prevention District Manager; Store Employees and Management; Law
Enforcement
Essential Job Functions
•
Observe, detect, and lawfully apprehend subjects involved in retail theft activities in accordance with
state laws relating to arrest, search and seizure, use of force, and any other governmental rules or
regulations pertaining to loss prevention activities.
•
Dress and act according to normal store customer appearance and behavior, so as not to appear as an
employee.
•
Utilize specialized tools, techniques, and equipment in surveillance activities.
•
Maintain awareness of circumstances and surroundings so as to perform duties in a safe, professional
manner.
•
Write comprehensible, legible, and accurate structured reports.
•
Appear in court or before other governmental boards and bodies and provide clear, concise, and accurate
verbal testimony during administrative or judicial proceedings.
•
Coordinate activities and interact well with store personnel and law enforcement agencies.
•
Comply with all company policies and procedures as they relate to surveillance and apprehension of
shoplift suspects.
•
Assist with the installation, maintenance, and repair of low voltage CCTV and various merchandise
alarm systems.
Physical Requirements
Occasionally = up to 1/3 shift
Frequently = up to 2/3 shift
Continuously = throughout shift
•
Standing: Continuously in combination with walking on concrete surface.
Bi-Mart Corporation
January 2008
•
Sitting: Occasionally.
•
Walking: Continuously in combination with standing.
•
Worker Mobility: Can change positions frequently throughout work shift. Must be able to defend self
in the event of a suspect attack.
•
Carry/Lift: Occasionally work independently with 0-45 pounds
•
Pushing/Pulling: Occasionally and independently push/pull 0-45 pounds.
•
Bending/Squatting: Occasionally throughout work shift.
•
Reaching/Handling: Use of fingers/hands/arms continuously. Occasional overhead reaching needed.
•
Grasping/Squeezing: Occasionally.
•
Twisting: Occasionally.
•
Climbing: Occasionally climb stairs to reach lunchroom, offices, stock/supply areas, etc.
•
Crawling: As needed.
•
Visual Ability: Use of vision continuously in ascertaining details involved in theft techniques.
Social Skill Requirements
•
Ability to positively interact with others.
•
Ability to skillfully communicate reasons for cooperation.
•
Ability to respond to information and communication from others.
•
Ability to apply required legal procedures to involved situations and communicate those details in
composed and professional demeanor.
Aptitude Requirements
•
Must qualify for and continually maintain all mandated certifications for employment as an unarmed
officer.
•
Must be able to read English and write it legibly.
•
Must be able to work independently and perform all duties without direct supervision.
•
Must have cognitive skills including ability to analyze, reason, and make on-the-scene decisions.
Bi-Mart Corporation
January 2008
•
Must be able to perform basic math functions.
•
Must be able to perform responsibilities in a reliable and confident manner.
•
Must be able to learn and retain new skills.
•
Must be able to understand principles of operation, and functionality, of low voltage mechanical and
video protection devices/systems and apply that understanding to correctly diagnose and repair system
failures.
Environmental Factors
•
Most work is performed in store.
•
Occasional exposure to outside elements.
•
Possible exposure to physical contact and contamination with suspect(s).
This position summary covers most of the duties performed; however, other duties and responsibilities not listed
may be assigned at the discretion of management.
After reviewing this position summary, can you perform all of the functions listed?  Yes
 No
If no to the above, please identify any functions that you are unable to perform:
I verify that I have thoroughly reviewed the position summary for Loss Prevention Officer and that I understand
the job requirements and essential job functions.
Signature: ___________________________________________________ Date: _______________________
Print Name: __________________________________________________
Bi-Mart Corporation
January 2008