APPLICATION FOR EMPLOYMENT
SUPERMARKETS
QSI, Inc., DBA Times Super Market, Big Save Markets, Fujioka’s Wine Times and Shima’s Market is an Equal Opportunity Employment Employer. We
do not discriminate against any applicant and we comply with all applicable federal and state employment laws. Provide only the information requested
on this application form and complete this entire application form. Failure to do so may result in the disqualication of your application.
VERY IMPORTANT: Print clearly (or type). If information provided is not legible, your application may be disqualied.
I am applying at Times because:
______Job Fair ______Friend/Family Member ______In-store sign ______City/State Program referral ______Applied on my own
Other:_________________________________________________________________________________________________________________
GENERAL INFORMATION:
Name: Last First M.I.
Address City State Zip
Referred By:
Social Security Number:
Telephone No.:
Home:
Cell:
Work:
Best time to call:
EMPLOYMENT INFORMATION:
Date you can start work:
Are you currently employed by us?
Rate Desired:
Have you ever been employed by us?
Position Applying For:
Have you ever applied with us before?
[ ] Yes [ ] No
If “Yes”, Store: Job:
[ ] Yes [ ] No
If “Yes”, When:
[ ] Yes [ ] No
If “Yes”, When:
AVAILABILITY:
Days:
Wednesday
Thursday Friday Saturday Sunday Monday Tuesday
Earliest Start Time:
Latest End Time:
Which areas of OAHU are you willing to work? (Please Circle)
Experience, skills, or qualications applicable to the position(s) you are applying for:
EMPLOYMENT RECORD: Starting with your present or most recent, list all previous employers. Include self-employment, military service,
summer, and part-time jobs. Please attach additional sheets, if necessary, following the same format.
Company Name: Phone:
Dates
Employed:
From:
To:
Position & Duties:
Salary:
Starting:
Ending:
Reason For Leaving:
Revised 7/22/15
Street Address City Zip
Supervisors Name:
Company Name: Phone:
Dates
Employed:
From:
To:
Position & Duties:
Salary:
Starting:
Ending:
Reason For Leaving:
Street Address City Zip
Supervisors Name:
Town
(Beretania, Liliha, Kahala, Kaimuki,
Kam Shopping Ctr, McCully, Fujioka’s Market City)
Leeward
(Aiea, Royal Kunia,
Mililani Town Ctr, Waimalu, Waipahu)
Windward
(Kailua, Kaneohe, Koolau,
Shima’s Waimanalo)
Email Address:
Which areas of the NEIGHBOR ISLANDS?
Maui
(Kihei, Honokowai)
Kauai
(Lihue, Koloa, Kapaa,
Eleele, Waimea, Hanalei)
®
3375 Koapaka Street, D-108 • Honolulu, HI 96819 • Phone: (808) 831-0811 • Fax: (808) 831-0830
OTHER:
Do you know anyone working for the Company? [ ] Yes [ ] No If “Yes”, Who:
MEDICAL AND CRIMINAL CONVICTION INFORMATION:
After an offer of employment is made, applicants may be required to undergo a physical and/or other medical examination at Company
expense and by a Company-chosen physician. Passing said examinations are a condition of employment.
I authorize the physicians conducting the examinations and any laboratory testing any specimen obtained by the physicians to disclose the
results of the examinations and the laboratory tests to the Company.
• The Company may inquire into and consider any criminal conviction record that you may have after it makes a conditional offer of
employment to you. The Company may withdraw a conditional employment offer if you have a criminal conviction record which bears a
rational relationship to the duties and responsibilities of the position for which you are applying. Any criminal conviction record that is more
than 10 years old or that involves certain Family Court matters will not be considered.
• Do you have a current Tuberculosis Clearance Card? [ ] Yes [ ] No Date last tested:
EDUCATION:
Name of School
Address Years Attended Degree/Diploma
Jr. High/Intermediate
High School
Company Name: Phone:
Dates
Employed:
From:
To:
Position & Duties:
Salary:
Starting:
Ending:
Reason For Leaving:
Street Address City Zip
Supervisors Name:
College
Other (Trade School, etc.)
Why would you like to work at Times, Big Save, Fujioka’s Wine Times or Shima’s?__________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
If you are hired, describe what you feel you can contribute to our Company or Store:_________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
IMPORTANT NOTICE:
It is policy of the Company to hire only U.S. citizens and aliens who are authorized to work in the U.S. As a condition of employment, you will be required to
produce original documents establishing your identity and authorization to work and to complete the U.S. Immigration and Naturalization Service’s Form I-9.
CERTIFICATION:
I certify that all statements made on this application are true and complete to the best of my knowledge. I understand that my application will not
be considered if it is incomplete. Further, I understand that any misrepresentation or omission will subject me to not being considered for hire
or, if said misrepresentation or omission is discovered after hire then it may result in immediate termination of employment. I hereby, authorize
any investigation of the above or related work experience, education, or reputation information for purposes of consideration of my application for
employment.
Notice to previous employers: I also authorize my previous employers to release any and all pertinent employment data to Times Super Market,
Big Save Markets, Fujioka’s Wine Times and Shima’s Market. This data will be used solely in its hiring process.
This application is not a contract and cannot create a contract. I understand that if I am employed by Times, Big Save, Fujioka’s Wine Times or
Shima’s my employment is “at will” and can be terminated at any time, either by myself or the Company, with or without cause or reason and with
or without notice.
Applicant’s Signature Application Date
Thank you for considering for your next job!!
SUPERMARKETS
Do you have a reliable means of transportation? [ ] Yes [ ] No
®