Employment Application * Denotes Required Information Today's Date: * Full Name * City * Address: * State -Please Select- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Fed. Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Marshall Islands Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota North Mariana Is Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Aguascalientes Baja California North Baja California Sur Campeche Coahuila Colima Chiapas Chihuahua Distrito Federal Durango Guanajuato Guerrero Hidalgo Jalisco Mexico Distrito Federal Michoacan Morelos Mayarit Nuevo Leon Oaxaca Puebla Queretaro Quintana Roo San Luis Potosi Sinaloa Sonora Tabasco Tamauilpas Tlaxcala Vera Cruz Yucatan Zacatecas Takagi Trinidad Belgium England Italy Santo Domingo Apartment Number: Phone Number: (xxx) xxx-xxxx * Email Address: * Confirm Email Address: * Are you of legal age to work? Yes   No

Are you a U.S. citizen? Yes    No Have you ever been convicted of a crime? (other than minor traffic violations) Yes    No If not a citizen - what type of visa? If yes, please explain. When does it expire?

Have you ever been employed by The RoomStore before?  Yes    No If yes, when? Supervisor's Name? Where?

PLACEMENT INFORMATION Position applying for? Hours Desired - Choose One - Full Time 40 hours Part Time 20 - 30 hours per week Temporary 14 - 90 days List days available: Sun M T W Th F Sat List hours available When would you be able to start work?

FOR OFFICE POSITIONS, PLEASE COMPLETE Office Machines you can operate? Do you type?  Yes   No WPM

EDUCATION High School Education?  Yes   No Name of High School? Year graduated or last attended? Did you graduate?  Yes   No College?  Yes   No Name of College Year graduated or last attended?

Pre-employment background checks and drug test are required on all new hires. ATTACH YOUR RESUME (Click "Browse/Choose File," select file to attach on your computer, then click "Attach/Open." Resume must be in Microsoft Word or PDF format). maximum file size is 2 megs

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