Application Form

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NAME
First Name*
Last Name*
Middle Name*
Social Security Number*
Address*
City*
State*
How Long?*
Email Address*
Phone Number*
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name
Address
City
State
Telephone Number
When Can You Start?
Part-Time or Full Time?
DAYS & HOURS AVAILABLE
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Compensation / Hourly Wage Expected?
Do You Have Transportation To and From Work?
- Yes
- No
EDUCATION
High School
Name Of School
Address
Last Yr. Completed
Last Yr. Attended
Major
College
Name Of School
Address
Last Yr. Completed
Last Yr. Attended
Major
EMPLOYMENT HISTORY (Start with the most recent employer)
Employer's Name, Address and Telephone Number
Date Employed
Position Held
Name & Title of Supervisor
Can we Contact?
- Yes
- No
Hourly Rate
Reason for Leaving?
Employer's Name, Address and Telephone Number
Date Employed
Position Held
Name & Title of Supervisor
Can we Contact?
- Yes
- No
Hourly Rate
Reason for Leaving?
Employer's Name, Address and Telephone Number
Date Employed
Position Held
Name & Title of Supervisor
Can we Contact?
- Yes
- No
Hourly Rate
Reason for Leaving?
Have you ever been discharged by a company?
- Yes
- No
If yes, give name of company(s) and reason:
Are you a U.S. citizen?
- Yes
- No
If no, do you have the legal right and necessary papers to work in the U.S.?
- Yes
- No
Have you ever been convicted of a felony or are any charges pending?
- Yes
- No
Lifting items up to 50lbs may be required in the course of your employment. Can you do this on your own or with a reasonable accommodation?
- Yes
- No
*Note: Applicants will not necessarily be disqualified if they have a felony conviction or are unable to perform a particular job duty.
Constant physical activity (assisting customers, stocking shelves, cleaning store and property, etc.) is necessary. Are you able to perform duties of this type throughout an entire shift on your own or with reasonable accommodation?
- Yes
- No
Have you ever worked for Cubbard Express Before?
- Yes
- No
Drug-Free Workplace

Bumgarner Oil Company maintains drug-free workplace. Applicants will undergo Drug and Alcohol Screen. A confirmed positive Drug and Alcohol Test will result in disqualification or termination from the employment.

The following questions relate to working conditions at Bumgarner Oil Company. Please answer the questions truthfully. Note: Answering "No" will not necessarily disqualify you from consideration.

Would You:
Work on your scheduled day off?
- Yes
- No
Work holidays?
- Yes
- No
Work a varied schedule?
- Yes
- No
Work nights and/or weekends?
- Yes
- No
Report to work on time?
- Yes
- No
Clean the parking lot and restrooms?
- Yes
- No
Wear a uniform and greet each customer with a smile?
- Yes
- No
Please explain any "No" answers below:
APPLICANT'S STATEMENT (Please Read Carefully)

In making this application for employment, I understand that an investigative report may be made whereby information is obtained through personal interviews with neighbors, friends and others with whom I am acquainted. This investigation includes information as to my character, general reputation, personal characteristics and mode of living. I understand I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigative consumer report.

I understand that the company reserves the right to require a medical examination of an employee at any time.

I hereby state that the information given by me in this application is true in all aspects, and I agree that if I am employed and the information is found to be false in any respect that I will be subject to dismissal without notice. I understand that employment entered into with Bumgarner Oil Company / Cubbard Express shall be for an indefinite term and shall be terminated at will by either myself or Bumgarner Oil Company / Cubbard Express without cause.
Referred By:
Date:
Applicant (Full Name):