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. Are you authorized to work 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. During the past five years have you been convicted of , or have you pleaded guilty or no contest to, a felony offense?*
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
Relationship:*
When is the best time to contact you?

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

I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for immediate dismissal. I understand that all such information is subject to verification by Corner Store, and hereby give my consent to Corner Store to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing that Corner Store may require at the time. Finally, I understand that submission of this application does not necessarily mean that I will be hired, and that if I am hired, my employment will be at will, and either I or Corner Store may terminate my employment at any; time, with or without notice or reason.
Signature*

Clear
Should be Empty:

Employment History