Careers / Employment

NAME

(Last)

(First)

(Middle)

Social Security Number

Address

City

State

How Long?

Telephone Number

Email

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

Day	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
To:
From:

Compensation / Hourly Wage Expected?

Are You 18 years or Older?  Yes No

Have You Ever Worked For Cubbard Express Before?  Yes No

Do You Have Transportation To and From Work?  Yes No

Education	Name Of School	Address	Last Yr. Completed	Last Yr. Attended	Major
High School
College / Technical

Employment History (Start with the most recent employer)

Employer's Name, Address and Telephone Number

Dates Employed From: To: Hourly Rate From: To: Position Held Name & Title of Supervisor Can we Contact?  Yes No Reason for Leaving?

Employer's Name, Address and Telephone Number

Dates Employed From: To: Hourly Rate From: To: Position Held Name & Title of Supervisor Can we Contact?  Yes No Reason for Leaving?

Employer's Name, Address and Telephone Number

Dates Employed From: To: Hourly Rate From: To: Position Held Name & Title of Supervisor Can we Contact?  Yes No 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

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.

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Referred By:

Date:

Applicant (Full Name):