Online Employment Application

NOTE: This is a long form and it cannot be saved. Please review for necessary information in advance and allow enough time to complete.

Personal Information
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Primary Phone Number*
Secondary Phone Number
Referred By
First Name Last Name
Employment Desired
Position*
Date You Can Start*
Preferred C-Store Location*
Salary Desired*
Are you employed now?*
- Yes
- No
May we contact your present employer?*
- Yes
- No
Have you applied to the company before?*
- Yes
- No
Where?
When did you apply?
Education
High School Attended*
Location*
First Year*
Last Year*
Did you graduate?*
- Yes
- No
College Attended
Location
First Year
Last Year
Did you graduate?
- Yes
- No
Trade, Business or Correspondence School
Location
First Year
Last Year
Did you graduate?
- Yes
- No
General Information
Subject of Special Study/Research Work
Special Training
Special Skills
U.S. Military or Naval Service
Rank
Former Employers (list below your last 4 employers starting with the most recent first)
Company*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From*
To*
Salary*
Position Held*
Reason for Leaving*
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Salary
Position Held
Reason for Leaving
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Salary
Position Held
Reason for Leaving
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Salary
Position Held
Reason for Leaving
References
(Give the names of 3 persons not related to you, whom you have known at least 1 year).
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business*
Years known*
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business*
Years known*
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business*
Years known*
Authorization
"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 and employers 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 the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities act (ADA) and other relevant federal and state laws I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment." In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document upon hire.
Today's Date*
Signature*
By entering your name and date, you certify that you are the applicant and you agree to the Authorization Statement above.

Personal Information

Employment Desired

Education

General Information

Former Employers (list below your last 4 employers starting with the most recent first)

References

Authorization