Andresen-Ryan coffee co.
2206 Winter Street
Superior   WI   54880
Phone 1-715-392-4771 or 1-800-283-2726
Fax 1-715-392-4776  Email: ruby@arcocoffee.com
APPLICATION FOR SALES EMPLOYMENT
(PRE-EMPLOYMENT QUESTIONNAIRE)    (AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER)
NAME         DATE:                        
LAST FIRST MIDDLE
DESIRED GEOGRAPHICAL LOCATION:
OPEN  
OTHER  
PLEASE WRITE OUT AT LEAST TWO EXAMPLES OF WHEN YOU'VE BEEN ABLE TO BE VERY INFLUENTIAL AND CHANGE
PEOPLE'S MINDS IN A DIFFICULT SITUATION.  INCLUDE (A) THE OBSTACLES YOU OVERCAME, (B) HOW YOU MADE
THEM UNDERSTAND YOU, (C) WHAT YOU SAID THAT IMPACTED THEIR CHANGE OF MIND, (D) WHAT ELSE YOU DID
AT THAT TIME THAT WAS ESPECIALLY USEFUL, AND (E) WHEN THE EXAMPLES OCCURRED.  USE ADDITIONAL
SPACE AS NEEDED.
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
SOCIAL SECURITY ARE YOU 18 YEARS OR OLDER?     YES         NO
NUMBER   (circle one)
PRESENT ADDRESS                                          
STREET CITY STATE ZIP
PERMANENT ADDRESS                                          
STREET CITY STATE ZIP
PHONE NUMBER   CELL NUMBER         EMAIL ADDRESS        
SPECIAL QUESTIONS                                        
DO NOT answer any of the questions in this framed area unless the employer has checked a box preceding a question thereby
indicating that the information is required for a bona fide occupational qualification or dictated by National Security Laws or is  
needed for other legally permissible reasons.  
   
   Height________feet _______inches     Are you prevented from lawfully becoming employed in the U.S.? ___YES ___NO
   
    Weight _______lbs    DATE OF BIRTH * ___________________  
   
    What Foreign Languages do you speak fluently? __________ Read ________ Write ________  
   
    Have you been convicted of a felony or misdemeanor within the last 5 years? ___YES ___NO **  
       Describe:                                          
                                           
*The Age Discrimination in Employment Act of 1967 prohibits dissemination  ... with respect to individuals who are at least 40 but less than   
70 years of age.  
**You will not be denied employment because of a conviction record unless the offense is related to the job for which you have applied.                      
EMPLOYMENT DESIRED DATE YOU MAY WE INQUIRE OF YOUR 
POSITION   CAN START   PRESENT EMPLOYER ?
NO YES NO
ARE YOU EMPLOYED NOW?  
WHAT IS THE BEST TIME ?  
EVER APPLIED TO THIS ARCO BEFORE ? ______ WHEN? _______
WORK HISTORY                                         
PRESENT OR LAST POSITION NEXT TO LAST POSITION 2ND TO LAST POSITION
DATES EMPLOYED FROM:          TO:        FROM:         TO:          FROM:           TO:          
COMPANY NAME                            
NAME & TITLE                            
OF SUPERVISOR                            
PHONE NUMBERS :
COMPANY                            
SUPERVISOR                            
BASE YEARLY EARNINGS :
STARTING                            
CURRENT                            
ADDITIONAL YEARLY EARNINGS :
BONUS                            
COMMISSION                            
TOTAL YEARLY EARNINGS :
STARTING                            
CURRENT                            
COMPANY CAR?          YES            NO          YES            NO              YES            NO                  
MILEAGE REIMBURSED? YES     NO     _____¢/MILE YES     NO     _____¢/MILE   YES     NO        _____¢/MILE  
EXPENSES PAID?          YES            NO          YES            NO          YES            NO
HEALTH INSURANCE? YES   NO   YOUR%____  CO % ____ YES   NO   YOUR%____  CO % ____     YES   NO  YOUR%____  CO % ____                  
NIGHTS AWAY PER MONTH PER MONTH     PER MONTH                
YOUR TITLE                            
TYPE OF INDUSTRY                            
EXACT DUTIES YOU PERFORMED
                           
                           
                           
                           
                           
PRODUCTS OR LINE SOLD
                           
                           
                           
NUMBER OF PEOPLE IN DIVISION
                           
NUMBER OF SALES PERSONNEL SUPERVISED
                           
HOW DO YOU RANK IN DIVISION ? IN DIVISION ?   IN DIVISION ?                
IN COMPANY ? IN COMPANY ?   IN COMPANY ?                
GEOGRAPHIC AREA YOU COVER
                           
GROSS $ VOLUME RESPONSIBILITY
STARTING                            
NOW                            
TWO PRESTIGE ACCOUNTS THAT YOU SELL
                           
                           
TWO OF YOUR COMPANY'S MAIN COMPETITORS
                           
                           
                                             
EDUCATION                 NAME & LOCATION  # OF YEARS SUBJECTS *DID YOU SUBJECTS
                 OF SCHOOL ATTENDED* STUDIED GRADUATE? STUDIED
                                             
GRAMMAR SCHOOL                      
                         
HIGH SCHOOL                      
                         
COLLEGE                      
                         
TRADE, BUSINESS OR
CORRESPONDENCE 
SCHOOL                      
                         
*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40
less than 70 years of age.
GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK                                    
                                             
Present membership in
US Military or Rank National Guard or Reserves
Reserve Status                                      
EDUCATION DEGREES I HAVE EARNED:
   
I HAVE EARNED THE TITLE
   
STARTING PAY DESIRED HERE AT ARCO:     
GOAL IN 1 YEAR:    
GOAL IN 5 YEARS:    
ARE YOU AVAILABLE TO WORK:
FULL TIME?  
PART TIME?  
HOURS AVAILABLE TO WORK
 MON:                   TUES:                   WED:                   THURS:                 FRI:                        SAT
FROM:       TO:       FROM:        TO:     FROM:        TO:     FROM:        TO:     FROM:        TO:       FROM:       TO:
TOTAL HOURS AVAILABLE TO WORK EACH WEEK:
 
FAVORITE KIND/BRAND OF COFFEE:
 
CHECK APPROPRIATE:
OWN HOME  
RENT  
BOARD  
# OF YEARS AT PRESENT RESIDENCE  
HOW DID YOU HEAR OF US?
NEWSPAPER  
PLACEMENT OFFICE  
JOB SERVICE  
PHONE BOOK  
REFERRED BY  
OTHER, SPECIFY  
I WILL TRAVEL THESE NUMBER OF DAYS PER MONTH:
1 TO 5  
6 TO 10  
11 +  
I WILL RELOCATE
IMMEDIATELY  
NO  
I WILL RELOCATE LATER, IF NECESSARY
WHEN   NUMBER OF MONTHS AFTER HIRE DATE  
Friends or relatives employed by ARCO Coffee:                                      
List hobbies, activities, or interests:                                        
                                                 
REFERENCES:
Give the names of three persons not related to you who have known you for at least one year:
NAME        ADDRESS           BUSINESS # YEARS
   PHONE POSITION ACQUAINTED
1.                      
               
2.                      
               
3.                      
               
PHYSICAL RECORD
Do you have any physical limitations that preclude you from performing the work for which you are being considered? ___YES___NO
PLEASE DESCRIBE                                        
                                           
IN CASE OF EMERGENCY
NOTIFY                                        
NAME ADDRESS PHONE NO.
"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU 
ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE
PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM AL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM
FURNISHING SAME TO YOU.
I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE
DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE."
DATE SIGNATURE                                  
                                           
DO NOT WRITE BELOW THIS LINE
INTERVIEWED BY DATE
                 
                                           
HIRED POSITION DEPARTMENT DEPARTMENT
  YES NO                                  
SALARY/WAGE     DATE REPORTING FOR WORK
                               
APPROVED  1.   2.       3.                  
Employment Manager Department Head General Manager
file:\\Arco01\company\Jamie\JOBAPPsales.xls Jan-09