Glen Ellen Village Market is an Equal Opportunity Employer, Race color, religion, age, sex, disability, marital or veteran status, place of national origin and other categories protected by law are not factors in employment, promotion, compensation or working conditions. Please fill out this form completely and send it to us immediately by pressing the Submit Button at the end of the document. If you prefer you can print out a copy of the four pages, fill them out completely, place in a envelope and mail it to Glen Ellen Village Market, 13751 Arnold Dr., Glen Ellen, CA 95442.
Application Information
Name:
Address:
City:     State     Zip
Phone (with area code): Message # (with area code):
Do you have a valid driver's license? Yes No  State:  License #:  
Have you ever applied to, or worked for Glen Ellen Village Market? Yes No
If yes, when?
Do you have any friends or relatives working for Glen Ellen Village Market? Yes No
If yes, state their name(s)
and relationship(s) 
How did you hear about us/this opening?
State briefly why you would like to
work for Glen Ellen Village Market:
Age you over 18 years of age? Yes No
Are you able to produce valid identification and proof of legal residence Yes No
Can you perform the essential functions of the job with or without reasonable accommodations? Yes No
If no, what type of accommodations
would enable you to perform the job?
General Information About Employment Desired
Position you are applying for: Full-time Part-time
If part-time, hours per week desired: Are you available on weekends: Yes No
Can you work holidays: Yes No   What days can you work: M T W T F S S
Hours you are available to work Are you available to be on-call Yes No
If hired, on what date would you start work:
Will you travel on company business: Yes No  Percent of time willing to travel 10 25 50 75
Hourly rate of pay or month salary desired: per hour per month
 
Education and training (including on-the-job training):
High School
School/Location/Sponsor:
 
Course of Study: Dates to  
Comm College
School/Location/Sponsor:
 
Course of Study: Dates to  
Trade School
School/Location/Sponsor:
 
Course of Study: Dates to  
College/University
School/Location/Sponsor:
 
Course of Study: Dates to  
Seminars/Other
School/Location/Sponsor:
 
  Course of Study: Dates to  
Special Skills
Do you speak, write or understand any foreign languages? Yes No
If yes, which language(s):
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at Glen Ellen Village Market. Yes No
If so, explain
in detail:
Licenses (list States):
Computer Skills
Hardware:
Dates Used
Level of Proficiency
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
Software
 
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
to
Entry Intermediate Advanced
Use the space below to summarize other relevant experience, skills and background that you may have
Employment History
List all previous employers starting with your present or
most recent position below (last 10 years is sufficient).
Name of Company: 
Name of Supervisor:
Address: 
City:     State     Zip
Telephone Number (with area code):
Position and Duties:
Employment Dates: to Starting Pay Rate: Ending Pay Rate:
Reason for Leaving:
Name of Company: 
Name of Supervisor:
Address: 
City:     State     Zip
Telephone Number (with area code):
Position and Duties:
Employment Dates: to Starting Pay Rate: Ending Pay Rate:
Reason for Leaving:
Name of Company: 
Name of Supervisor:
Address: 
City:     State     Zip
Telephone Number (with area code):
Position and Duties:
Employment Dates: to Starting Pay Rate: Ending Pay Rate:
Reason for Leaving:
 
Please read and Initial Each Paragraph Below (if there is any part of this page you do not understand, please ask the interviewer about it before signing).
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or immediate discharge if I am employed, regardless of the time elapsed before discovery.
(initial) 
I hereby authorize Glen Ellen Village Market to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Glen Ellen Village Market. my current employer and former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
(initial)
I understand that if offered employment, the offer is contingent on my passing a pre-employment alcohol and drug screen and a pre-employment physical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and pre-employment physical upon receipt of a verbal offer of employment .I understand that failure to pass the alcohol/drug screen and/or physical will result in withdrawal of the employment offer.
(initial)
If hired, I also agree to submit to alcohol or drug testing as a condition of employment. I agree that Glen Ellen Village Market may conduct alcohol or drug screening at its sole discretion with or without notice, with or without cause or reason. I also understand that refusal to submit to a random alcohol/drug screen will be considered a voluntary resignation of employment.
(initial)
I understand that nothing contained in the application or conveyed to me during any interview which may be granted, in intended to create an employment contract, implied or explicit, between me and Glen Ellen Village Market. In addition, I understand and agree that if I am employed, my employment relationship with Glen Ellen Village Market is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Glen Ellen Village Market and that no promises or representations contrary to the foregoing are binding on Glen Ellen Village Market unless made in writing and signed jointly by the President/CEO and myself.
(initial)
Furthermore, if employed, I agree that any dispute arising out of the termination of our employment relationship shall be resolved pursuant to mandatory binding arbitration at the written request of either Glen Ellen Village Market or myself. This agreement provides that such arbitration shall comply with and be governed by the Federal Arbitration Act and that any arbitration award arising from such dispute shall be limited to back pay.
(initial)
I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or Glen Ellen Village Market benefits, policies and procedures will not alter the at-will and arbitration agreements.
(initial)
I understand that if offered employment. I will as a condition of employment, be required to submit proof of my identify and legal right to work in the United States on my first day of employment.
(initial)
If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid California State Driver's License and understand that I will be required to provide a copy of my official driving record and proof of insurance. I also understand that any offer of employment is contingent on my ability to be covered by Glen Ellen Village Market auto insurance, if required for my position.
(initial)
My signature below certifies that I have read and understand these complete pages, and agree to the terms and conditions outlined in this document.
Applicant Signature
Date