Please fill out the form below as completely as possible. 
Click the "Submit" button at the bottom of the form when you are satisfied with your answers.

 

Position(s) You are Interested In:

Management
Meat Dept.
Produce Dept.
Deli Dept.
Stock Crew
Cashier
Package Clerk
  

Your Contact Information:

Full Name
Address
City
State
Home Phone (With Area Code)
Work or Cell Phone (With Area Code)
E-Mail Address

 

Please List Your Last 3 Employers:

First Employer

Employer
City
Years/Months

  Yes, You May Contact This Employer

 Second Employer
Employer
City
Years/Months

  Yes, You May Contact This Employer

 Third Employer

Employer
City
Years/Months

  Yes, You May Contact This Employer

 

 

Check All that Apply:

  I am 18 Years or Older   I Have a Valid Driver's License
  I Finished High School   I Have Attended or am Currently Attending College
  How Many Years Have You Attended College?
Please List the Name and Phone Number Including Area Code of 2 Personal References (person not related to you whom you have know at least 1 year): 

First Reference

Name
Phone Number
(With Area Code)

 

Second Reference

Name
Phone Number
(With Area Code)

 

 

Please List the Name and Phone Number Including Area Code of 2 Business  References:

First Reference

Name
Phone Number
(With Area Code)

Second Reference

Name
Phone Number
(With Area Code)

 

 

Additional Information:

Have Other Training?
 Comments?
  Yes, I am Legally Eligible for Permanent Employment in the U.S.A.

  I understand that by applying for employment to Langley Inc. I may be subject to a
         background check, periodic, random drug tests or polygraph testing.