Job Application for Corner Store Travel Center

Employment History

List your current or most recent employment history
Are you currently employed?*
May we contact your current or most recent employer?*

YesNo
If no, list reason we may not contact:
Name of Company currently or most recently employed with:*
**IF YOU ARE NOT CURRENTLY EMPLOYED PLEASE TYPE IN 'NOT EMPLOYED'
What is/was your position?*
Last Position You Held
Who is/was your supervisor/manager?*
Immediate Supervisor(s)
Business Phone Number:*
Phone Number(s)
Job Time & Pay:*

Dates of EmploymentMost Recent Salary or Hourly Rate
Hours Worked & Reason for Leaving:*

Hours worked per Week Reason for Leaving
Other Past Employers
Company:
Position:
Time worked there:
years and/or months
Hourly Rate:
Reason for Leaving:
Please list any other jobs or qualifications you have:*
Education
Did you finish High School?*

Yes I graduatedNo I didn't
If yes, what year did you graduate?
Professional Reference

co-worker, past employer, boss etc.
Name:*

First NameLast Name
Phone Number:*
Relationship: *
co-worker, past employer, boss etc.
Years Known:*
We may contact this professional reference:*

YesNo

1. Can you provide proof of eligibility to become employed in the United States?*
2. What can you provide for proof of eligibility of employment? *
3. Have you ever filled out a job application with Corner Store before?*
3b. If yes, what date did you apply:

MonthDayYear
4. Do you have relatives who currently are employed with Corner Store?*

YesNo
4b. If yes, who is the relative?
5. Do you have adequate transportation to meet travel requirements of the job?*
6. Are you able and willing to travel for this job if travel is necessary?*
7. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
7b. If yes, please explain and describe what accommodations might be necessary:
8. Have you ever been terminated or forced to resign from your employment with any employer?*
8b. If yes, provide Termination or Forced Resignation Reason:
9. Have you ever been convicted of a crime including any driving and/or alcohol related offenses?*
9b. If you answered yes on question 9, please explain:
10. If asked, are you willing to consent to a background check?*

YesNo

Emergency Contact*

NamePhoneE-Mail
When is the best time to contact you?

Morning (8 a.m. - 12 p.m.)Afternoon (1 p.m. - 5 p.m.)
Disclaimer

To ensure this application acceptable, please print or type with the application being fully completed for it to be considered. I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated. I acknowledge and understand that the company is an "at will" employer. Therefore, any employee may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.
Signature*

Clear
Should be Empty:

Employment History