Dick Blick Holdings, Inc. & Subsidiaries

Application for Employment

We appreciate your consideration of Dick Blick as a potential employer. Please complete this form in its entirety to assist us in evaluating your qualifications. If you need help in completing this form, please ask and every effort will be made to assist you. It is the policy of Dick Blick Holdings, Inc. & Subsidiaries to provide equal employment opportunity without regard to age, sex, race, creed, national origin or disability.

Personal Information

Name / Date
Address / SS#
City/State/Zip / Home Phone
Position Applied for / Business Phone
Full Time: / Part Time: / Seasonal: / Shift/Hours:
Have you been interviewed by Dick Blick previously? / Yes: No: / Mo/Yr:
Have you been employed by Dick Blick previously? / Yes: No: / Mo/Yr:
Do you have friends/relatives employed by Dick Blick? / Yes: No: / Name:
Date you are available to work: / Salary rate desired:
Are you legally eligible for employment in the United States? / Yes: No:
Have you ever been convicted of a felony? (A conviction will not necessarily disqualify you from consideration.) / Yes: No: / Explain:
Please list any skills or qualifications you believe may be valuable to Dick Blick?
How did you hear about this position? / Newspaper Ad:
Recruiter: / Friend/Relative:
Radio Station:
Other:

Education

Level / Name and Location of School / Field of Study / Years Completed / Did you graduate? / Degree Received
High School or GED / Yes: No:
College / Yes: No:
Graduate / Yes: No:
Other / Yes: No:

Employment Record. Please list all present and past employment, beginning with your most recent position. Correct phone numbers and supervisor names are very important. Use extra sheets if necessary.

Company Name: / Dates employed:
Address: / Salary/rate:
City/State/Zip: / Phone:
Job Title: / Supervisor:
Duties:
Reason for leaving:
Company Name: / Dates employed:
Address: / Salary/rate:
City/State/Zip: / Phone:
Job Title: / Supervisor:
Duties:
Reason for leaving:
Company Name: / Dates employed:
Address: / Salary/rate:
City/State/Zip: / Phone:
Job Title: / Supervisor:
Duties:
Reason for leaving:

References Please list references that know about your work/education background. Is any additional information about your name (name change, assumed name, nickname) needed to complete a reference check?

Name: / Address:
Phone: / City/State/Zip:
Name: / Address:
Phone: / City/State/Zip:

I state the information provided in this application is true and correct. I understand that providing false, incomplete, or misleading information may void this application or result in termination of employment, if offered and accepted. I understand that if offered employment either I, or the Dick Blick Holdings, Inc. & Subsidiaries, has the right to terminate that employment at any time, with or without cause or notice. I understand this is not an employment contract. I authorize my former employers, references, law enforcement authorities, and schools to release information concerning my background, work record, work habits, work performance, and disciplinary action and, release them from liability for providing this information.

______

Signature