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Uwajimaya On-line Job Application Form
First Name:    MI:    Last Name:  
Address:
City: State:   Zip:  
Home Phone:    (no dashes) ie: 2061231234
Alternate (Cell) Phone:    (no dashes) ie: 2061231234
Email Address:
Position:         
Store Location:

Have you ever been employed at Uwajimaya?

 Yes No
Are you legally entitled to work at in the United States?  ( proof of right to work is required )

 Yes No
Have you been convicted of a felony in the last 10 years that reasonably relates to the job you are applying for? (a conviction may not necessarily eliminate you as a candidate for employment.)
  Yes No

If yes, please indicate the date and nature of offense:  
How were you referred to us?       
Date available to work:   (ie: 01/01/2001)     If under 18, please state your age:  
Language Skills:

Languages:   read:   write:   speak:  
Languages:   read:   write:   speak:  
Languages:   read:   write:   speak:  


Have you ever been employed? If yes, please fill out the following. Yes No

Beginning with current/most recent employer or status, list in DATE ORDER all periods of employment and voluntary work. If employed, may we contact your employer?
  Yes No

Employer: 
Business:     Phone:    (ie: 2061231234)
Address:    City:    State:  
Duties: 
Supervisor:    Title:   Phone:    (ie: 2061231234)
Dates worked from:    (ie: 01/02/00)  To:    (ie: 01/02/00)
Reason for leaving:  

Employer: 
Business:     Phone:    (ie: 2061231234)
Address:    City:    State:  
Duties: 
Supervisor:    Title:   Phone:    (ie: 2061231234)
Dates worked from:    (ie: 01/02/00)  To:    (ie: 01/02/00)
Reason for leaving:  

Employer: 
Business:     Phone:    (ie: 2061231234)
Address:    City:    State:  
Duties: 
Supervisor:    Title:   Phone:    (ie: 2061231234)
Dates worked from:    (ie: 01/02/00)  To:    (ie: 01/02/00)
Reason for leaving:  
Application Information Release
Please read carefully and check the appropriate box, or your application will not be processed. This application was completed by me and all information provided is true and complete to the best of my knowledge. I authorize Uwajimaya, Inc. to investigate all statements contained in this application and to request information about me from previous employers and educational institutions. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. I also release all parties and persons connected with any requests for information from all claims, liabilities and damages for false or misleading information in this application may be cause for denial of employment or for dismissal, if employed. I understand that employment at Uwajimaya, Inc. is on an "At-Will" basis. That is, if employed by Uwajimaya, Inc., employment is for no definite period and may be terminated, at any time, with or without notice, by either party.

I also understand that if employed, I must comply with all current and subsequently issued company policies including the drug-free policy in accordance with the US Department of Transportation.
Name of Applicant:  Acknowledgement: Yes No




Uwajimaya is an equal opportunity employer and is committed to providing an equal opportunity before and during employment regardless of race, color, religion, gender, sexual orientation, age, national origin, political affiliation, disability, marital status, or other similar factors not related to job requirements.