Big Lots Job Application Form

To join Big Lots retail store as an employee, interested individual must complete this form and submit it to the manager of the preferred branch.Download

Extracted Text for Proper Search

Name (Last, First, Middle) Contact Phone Number
Street Address  Social Security Number
City  State Zip E-mail Address
Position(s) interested in? 
 
Salary Requirements  Are you under the age of 18? Yes No
     Hour/Year (Circle One)  If yes, state your age.  
Have you ever worked for any Odd Lots, Big Lots, Mac Frugal’s, Pic ‘N’ Save, All For One, ITZADEAL, Toy Liquidators, Toys Unlimited, Amazing Toy Stores,  
K•B Toys, K•B Toy Outlet, K•B Toy Works or other Big Lots locations before?  Yes No
If yes, when and where?  
If hired, can you supply proof that you are legally entitled to work in \
the United States for any employer?  Yes No
Do you have friends or relatives working for us?  Yes No
If so, who?  
Can you work:  Anytime Days Evenings Weekends
Are there any times or days you cannot work?  
Have you ever been convicted of a felony, a violent crime, or retail related crime (i.e., shoplifting, credit c\
ard fraud, robbery, theft, burglary)?        Yes     No
Note: A “yes” response will not automatically disqualify you from \
employment, but will be considered as part of your overall job-related qualifications for 
employment. You do not need to disclose any information regarding arrests or any criminal charges and/or convictions that have been erased, annulled, sealed 
and/or expunged from your record.
If yes, please describe:  
 	
BIG LOTS
EMPLOYMENT APPLICATION
This application is considered active for ninety (90) days.	
DRUG-FREE WORKPLACE
All employees are subject to drug and alcohol testing  procedures permitted under federal and state law.	
WOTC Registration #     	PERSONAL DATAPlease complete in ink.
EDUCATION
Type of School  Name of School  Location of School Area of Study 
Last Year  Did You Earn a  
      Completed Degree or Diploma?
High School  1  2  3  4 Yes No
College  1  2  3  4 Yes No
Graduate  1  2  3  4 Yes No
Other  1  2  3  4 Yes No
REFERENCESList names of three people (other than relatives) we may contact who h\
ave knowledge of your job-related skills.	
  Name    Telephone Contact/Email Contact  Address/City/State Occupation	
1
2
3	
AN EQUAL OPPORTUNITY EMPLOYER
Big Lots is an Equal Opportunity Employer and does not discriminate in making employment decisions\
 based upon race,   color, sex, religion, national origin, age, disability, marital status, sexual orientation, or veteran or military status.	
 SOS SKU# 960600043 • 08/10
CONTINUED ON BACK

EMPLOYMENT HISTORY
BEGINNING WITH YOUR MOST RECENT EMPLOYER, LIST ALL EMPLOYMENT INCLUDING MILITARY SERVICE AND SELF-EMPLOYMENT. Please account 
for all periods of unemployment. All sections of this application must b\
e complete even if a resume is attached.
If presently employed, may we contact your employer for references?  Yes No May we contact you at your place of employment?  Yes No
I understand that Big Lots may contact the past employers and/or persona\
l references I have provided in order to verify my past employment and 
work record. I authorize all past employers, educational institutions, g\
overnment agencies and/or personal references to release any and all information 
concerning my past employment work history, performance, and personal character. I hereby release all such employers, personal references, and Big 
Lots from any and all liability resulting from damages I may incur in th\
e reference verification process. I understand that my employment or c\
ontinued 
employment is contingent upon my successfully completing both reference \
and background checks. I also understand that if employed by Big Lots, my employment is “at \
will” and can be terminated at any time for any reason either by myself or the 
Company. This agreement cannot be modified by any representative of the Compa\
ny either in writing or verbally. Finally, I understand it is unlawful for Big Lots to employ anyone who is neith\
er a citizen of the U.S. nor an alien authorized to work in the U.S. I c\
ertify 
that any U.S. citizenship/work authorization information I provide to the Company is authentic. Further, I certify that all information I have provided on this 
application is accurate. False information or omission of facts on this application may result in the termination of my employment with Big Lots.
  Applicant’s Signature  Date
Thank you for your interest and the time you have taken to submit this a\
pplication.
Name of present or last employer
Address
City, State, ZIP
Phone Number   ( ) Job Title/Responsibilities
Was your position 
Full time Part time	
Reason for leaving  Terminated Voluntary Involuntary
Explain	
From (Mo. & Yr.)  To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $	
Name of previous employer
Address
City, State, ZIP
Phone Number   ( )
Name of previous employer
Address
City, State, ZIP
Phone Number   ( )
Name of previous employer
Address
City, State, ZIP
Phone Number   ( )
Name of previous employer
Address
City, State, ZIP
Phone Number   ( )	
From (Mo. & Yr.)  To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $
From (Mo. & Yr.) To (Mo. & Yr.)
Supervisor Name
Starting Salary $
Last Salary $	
Job Title/Responsibilities
Was your position  Full time Part time
Reason for leaving  Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position  Full time Part time
Reason for leaving  Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position  Full time Part time
Reason for leaving  Terminated Voluntary Involuntary
Explain
Job Title/Responsibilities
Was your position  Full time Part time
Reason for leaving  Terminated Voluntary Involuntary
Explain

OMB  No.  1545-1500
 	Form
 	8850
 	
Department  of  the  Treasury
Internal  Revenue  Service
 	
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency 
for the work opportunity credit.
 
2
 
3
 
I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 
9  months  during  the  past  18  months.
 	
Cat.  No.  22851L
 	
Pre-Screening  Notice  and  Certification  Request  for
the  Work  Opportunity  Credit
 	
Form	8850	(Rev.  8-2009)
 
(Rev.  August  2009)
 	
Job  applicant:  Fill  in  the  lines  below  and  check  any  boxes  that  apply.  Complete  only  this  side.
 	
Your  name
 
Street  address  where  you  live
 
City  or  town,  state,  and  ZIP  code
 
Received  SNAP  benefits  (food  stamps)  for  the  past  6  months,  or
 
Job  applicant’s  signature	

 	
If  you  are  under  age  40,  enter  your  date  of  birth  (month,  day,  year)
  Social  security  number	

 	
//
 	
I  am  a  veteran  and  a  member  of  a  family  that  received  Supplemental  Nutrition  Assistance  Program  (SNAP)  benefits
(food  stamps)  for  at  least  a  3-month  period  during  the  past  15  months.
 
 I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work 
program,  or  the  Department  of  Veterans  Affairs.
 
 I  am  at  least  age  18  but  not age  40  or  older  and  I  am  a  member  of  a  family  that:
 
 During  the  past  year,  I  was  convicted  of  a  felony  or  released  from  prison  for  a  felony.
 	
Received  SNAP  benefits  (food  stamps)  for  at  least  3  of  the  past  5  months,  but is  no  longer  eligible  to  receive  them.
 	
Under  penalties  of  perjury,  I  declare  that  I  gave  the  above  information  to  the  employer  on  or  before  the  day  I  was  offered  a  job,  and  it  is,  to  the  best  of  my
knowledge, true, correct, and complete.
 	
Date
  //
 	
For  Privacy  Act  and  Paperwork  Reduction  Act  Notice,  see  page  2.
 
County
 	
See  separate  instructions.
 	
Check  here  if  any of  the  following  statements  apply  to  you.
 
Check  here  if  you  are  a  member  of  a  family  that:
 
 Received  TANF  payments  for  at  least  the  past  18  months,  or
 
 Stopped  being  eligible  for  TANF  payments  during  the  past  2  years  because  federal  or  state  law  limited  the  maximum 
time  those  payments  could  be  made.
 
I  received  supplemental  security  income  (SSI)  benefits  for  any  month  ending  during  the  past  60  days.
 
5
 	
Signature—All  Applicants  Must  Sign
 
1
 	
Check here if you are completing this form 
before August 28, 2009, and you lived in the area impacted by Hurricane Katrina 
on  August  28,  2005.  If  so,  please  enter  the  address,  including  county  or  parish  and  state  where  you  lived  at  that  time.
 
 Received TANF payments for any 18 months beginning after August 5, 1997,  and the earliest 18-month period beginning 
after  August  5,  1997,  ended  during  the  past  2  years,  or
 
Check  here  if  you  are  a  veteran  entitled  to  compensation  for  a  service-connected  disability  and, during  the  past  year,
you  were:
 
 Discharged  or  released  from  active  duty  in  the  U.S.  Armed  Forces,  or
 
4
 
Unemployed  for  a  period  or  periods  totaling  at  least  6  months.
 	
Telephone  number
 	() -
 
 I  am  a  veteran  and  I  was  discharged  or  released  from  active  duty  in  the  U.S.  Armed  Forces  during  the  past  5  years
and,  for  at  least  4  weeks  during  the  past  year,  I  received  unemployment  compensation.
 
 I  am  at  least  age  16  but  not age  25  or  older,  and:
 
During  the  past  6  months,  I  have  not  attended  a  secondary,  technical,  or  post-secondary  school  for  more  than
an  average  of  10  hours  per  week,  not  counting  periods  during  which  the  school  was  closed  for  scheduled
vacations,  and
 
b 
  During  the  past  6  months,  if  I  was  employed,  during  each  consecutive  3-month  period  within  the  past  6  months,
I  earned  less  than  I  would  have  earned  if  I  had  worked  for  the  applicable  minimum  wage  30  hours  every  week
during  the  3-month  period, 
and
 
a
  a
 
b
 
c
 
I  do  not  have  a  certificate  of  graduation  from  a  secondary  school  or  a  General  Education  Development  (GED)
certificate 
or I  have  a  certificate  that  was  awarded  at  least  6  months  ago  and  I  have  not  held  a  job  (other  than
occasionally)  or  been  admitted  to  a  technical  or  post-secondary  school  since  I  received  the  certificate.

Page	2
 	Form  8850  (Rev.  8-2009)
 	
For  Employer’s  Use  Only
 	
Employer’s  name
 
City  or  town,  state,  and  ZIP  code
 
Date  applicant:
 Telephone  no.
 
Street  address
 
Under  penalties  of  perjury,  I  declare  that  the  applicant  provided  the  information  on  this  form  on  or  before  the  day  a  job  was  offered  to  the  applicant  and
that  the  information  I  have  furnished  is,  to  the  best  of  my  knowledge,  true,  correct,  and  complete.  Based  on  the  information  the  job  applicant  furnished  on
page  1,  I  believe  the  individual  is  a  member  of  a  targeted  group.  I  hereby  request  a  certification  that  the  individual  is  a  member  of  a  targeted  group.
 
Gave
information
  Was
offered  job
 Was
hired
 Started
job
 
Employer’s  signature	

 	
//  
//
  //
 
//  
//
 	
Title
  Date
 
EIN	

 	
If,  based  on  the  individual’s  age  and  home  address,  he  or  she  is  a  member  of  group  4  or  6  (as  described  under  Members
of  Targeted  Groups  in  the  separate  instructions),  enter  that  group  number  (4  or  6)	
 	
() -
 
Person  to  contact,  if  different  from  above
 
City  or  town,  state,  and  ZIP  code
  Telephone  no.
 
Street  address
 	
() -  	
Privacy  Act  and
Paperwork  Reduction
Act  Notice
 
Section  51(d)(13)  permits  a  prospective
employer  to  request  the  applicant  to
complete  this  form  and  give  it  to  the
prospective  employer.  The  information
will  be  used  by  the  employer  to
complete  the  employer’s  federal  tax
return.  Completion  of  this  form  is
voluntary  and  may  assist  members  of
targeted  groups  in  securing  employment.
Routine  uses  of  this  form  include  giving
it  to  the  state  workforce  agency  (SWA),
which  will  contact  appropriate  sources
to  confirm  that  the  applicant  is  a
member  of  a  targeted  group.  This  form
may  also  be  given  to  the  Internal
Revenue  Service  for  administration  of
the  Internal  Revenue  laws,  to  the
Department  of  Justice  for  civil  and
  The  time  needed  to  complete  and  file
this  form  will  vary  depending  on
individual  circumstances.  The  estimated
average  time  is:
 
Recordkeeping 	
3  hrs.,  16  min.
 
Learning  about  the  law
or  the  form 	
46  min.
 
Preparing  and  sending  this  form
to  the  SWA 
42  min.
 
If  you  have  comments  concerning  the
accuracy  of  these  time  estimates  or
suggestions  for  making  this  form
simpler,  we  would  be  happy  to  hear
from  you.  You  can  write  to  the  Internal
Revenue  Service,  Tax  Products
Coordinating  Committee,
SE:W:CAR:MP:T:T:SP,  1111  Constitution
Ave.  NW,  IR-6526,  Washington,  DC
20224.
  Do  not  send  this  form  to  this  address.
Instead,  see  When  and  Where  To  File  in
the  separate  instructions.
 	
Section  references  are  to  the  Internal
Revenue  Code.
 	
Form 	8850 	(Rev.  8-2009)
 	
criminal  litigation,  to  the  Department  of
Labor  for  oversight  of  the  certifications
performed  by  the  SWA,  and  to  cities,
states,  and  the  District  of  Columbia  for
use  in  administering  their  tax  laws.  We
may  also  disclose  this  information  to
other  countries  under  a  tax  treaty,  to
federal  and  state  agencies  to  enforce
federal  nontax  criminal  laws,  or  to
federal  law  enforcement  and  intelligence
agencies  to  combat  terrorism.
  You  are  not  required  to  provide  the
information  requested  on  a  form  that  is
subject  to  the  Paperwork  Reduction  Act
unless  the  form  displays  a  valid  OMB
control  number.  Books  or  records
relating  to  a  form  or  its  instructions  must
be  retained  as  long  as  their  contents
may  become  material  in  the
administration  of  any  Internal  Revenue
law.  Generally,  tax  returns  and  return
information  are  confidential,  as  required
by  section  6103.
 
State  and
county  or
parish  of  job
 
Check if the individual was not your employee 
on August 28, 2005, and this is the first time 
the  employee  has  been  hired  by  you  since
August  28,  2005.
 	
Complete  Only  If  Box  1  on  Page  1  is  Checked
 	
Elizabeth Henricks c/o First Advantage
888570 4455
First Advantage, 9025 N. River Rd., Suite 300
Indianapolis, IN 46240 31        1186811