APPLICATION FOR EMPLOYMENT
Equal Opportunity Employer
Thank you for your interest in joining our team. Energetic employees are key contributors to the exceptional service we provide our
guests. We do not discriminate on the basis of race, religion, veteran status, color, sex, age, national origin, disability, or any other
protected class. If you are team-oriented and customer-focused, then Gumby’s, Geno’s or an affiliated company is the right place for you!
EMPLOYMENT OPPORTUNITIES—indicate your preference:
Company:
Position:
Gumby’s
Geno’s
Other (list below)
_________________
Cashier
Manager
Last Name
Other Position (list below)
______________________
First Name
M.I.
State:
Zip:
Primary Email Address (optional):
Address:
City:
Phone Number:
Cell Phone Number (optional):
Can you, at the time of employment, submit
verification of your legal right to work in the
U.S?
YES
Federal law prohibits discrimination in
employment because of age.
Are you 18 or older? If NO, give age:______
NO
If driving is an essential function of the job, do you
have a valid driver’s license?
YES
NO
YES
If YES, please list license number:____________State____
NO
Have you ever been terminated from a previous employer or asked to leave?
Yes
No If YES, please
explain:______________________________________________________________________________________________________
TELL US ABOUT YOUR AVAILABILITY
Your desired hours of availability may impact your schedule. Certain positions and store locations require flexibility in hours worked.
Willing to work Holidays?
Yes
DAY:
Monday
Sunday
No
Willing to work Weekends?
Tuesday
Wednesday
Thursday
Yes
No
Friday
Saturday
FROM:
TO:
How did you hear about Gumby’s / Geno’s? __________________________________________________________________
Have you ever been employed by Gumby’s, Geno’s and/or any affiliated company?
Yes
No
If YES, please indicate when ______________ and where__________________________________________________________
During the past 7 years, have you been convicted of or pled guilty to a crime, excluding misdemeanors and traffic violations?
YES
NO
If YES, describe in full: (A conviction will not necessarily bar you from employment.)___________________________
West Virginia Lottery Regulations (sections 29-22B-702 and 29-22B-1602) require those working with or around video lottery
machines to be age 21. This will be considered for store location employment which has lottery machines. Are you age 21 or
older as of the completion date of this employment application?
Yes
NO
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EDUCATION
Name of School, City, State
Number of Years
Completed
Major
Grade
Average
High School
Vocational or
Business School
College or
University
Certifications
REFERENCES
– Provide three we
may contact
Title (i.e., Supervisor,
Director, etc.)
Please explain how you
know this reference:
co-worker, family
member, friend, teacher,
etc.
Contact Phone Number(s) – list
more than one if needed
E-mail Address – list more than one if
needed
EMPLOYMENT HISTORY
Instructions: Beginning with the last or present employer, list the three most recent employers for whom you have worked, whether fulltime or part-time. May we contact your current and/or previous supervisors?
YES
NO
Date Employed
FROM (Mo/Yr)
Date Employed TO
(Mo/Yr)
Last Rate of Pay
Hrs. per Week
Company Name
Supervisor’s Name/Title
Phone Number of
Employer
Description
of Position
Position
Reason for Leaving
To the best of your knowledge, would this employer rehire you?
Date Employed
FROM (Mo/Yr)
Date Employed TO
(Mo/Yr)
Last Rate of Pay
Hrs. per Week
YES
Company Name
Supervisor’s Name/Title
Phone Number of
Employer
Description
of Position
Position
Reason for Leaving
To the best of your knowledge, would this employer rehire you?
Date Employed
FROM (Mo/Yr)
Date Employed TO
(Mo/Yr)
Last Rate of Pay
Hrs. per Week
NO
YES
NO
Company Name
Supervisor’s Name/Title
Phone Number of
Employer
Description
of Position
Position
Reason for Leaving
To the best of your knowledge, would this employer rehire you?
YES
2
NO
EMPLOYMENT APPLICATION DISCLOSURE, ACKNOWLEDGEMENT, AND CONSENT
I understand and acknowledge that I am applying for a position with Gumby’s, Geno’s and/or an affiliated company, also
referred to and represented by the term “Company.” If I am employed, I agree that my employment with the Company is at
the will of the Company, which means that I can choose to leave the company at any time and the Company has the right
to discharge me for any reason or no reason, with or without notice. I also understand that I may be terminated or laid off at
the discretion of the Company. I expressly agree and understand that my employment is “at will” with regard to discharge,
termination, and/or layoff, and it may only be changed in writing, signed by the President of the Company. I agree to abide
by and conform to the Company’s rules, policies, and procedures and future conditions of employment that the Company
may adopt at its sole discretion.
I affirm that all information on this application is true and complete and also understand that false information, intentional
deception, and/or any omission of data will result in disqualification of employment consideration or dismissal, if employed.
In connection with my application for employment, I also understand that as a condition to obtaining employment at the
Company, I must successfully complete any and all necessary post offer, pre-employment checks and screens as may be
applicable for the position(s) for which I am applying, such as, but not limited to, drug screen, physical, credit check,
criminal background check, reference checks, driver’s license checks, etc.).
Therefore, in connection with my application for employment, I hereby authorize and indemnify, any education institution,
past or present employer, law enforcement agency, or any person who has knowledge of my education, work experience,
and/or criminal conviction record to release this information to the Company’s agents or designated representatives. I
hereby release all persons and companies/organizations from any and all liability as a result of them providing true and
accurate information.
READ CAREFULLY BEFORE SIGNING: By signing this agreement, I am confirming that I have read and understand this
entire employment application and this acknowledgement disclosure, while also affirming that I am fully able and
competent to complete it.
I have either read and/or a company representative has explained to me the job requirements for the specific position for
which I am applying and I acknowledge that that I can perform all essential job duties and other duties/responsibilities
described.
Applicant’s Signature:
Date:
Revised: 4-2014, 1-2015
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