Job Application: Gas Attendant (Lakewood)

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Personal Information

Name (First, Middle, Last)
Email Address

Address
City
State
Zip Code
Phone

Desired Shift (Part Time or Full Time)
Referral Source

Are you currently authorized to work in the US?	Yes No

If Yes, is your work authorization based upon a nonimmigrant visa?	Yes No

Are you at least 18 years of age?	Yes No

Have you ever applied with us before?	Yes No
If Yes, when? (Month, Year)

Are you able to perform the essential functions of the position without reasonable accommodation?	Yes No

Do you claim Indian tribe preference?	Yes No
If Yes, enter Tribe and Enrollment Number
Do you claim Spousal-Tribal preference?	Yes No

Employment History

Last/Current Employer
Position Title
Supervisor Name
Supervisor Phone
May we contact employer?	Yes No
Date Employment Began
Date Employment Ended
Final Base Salary
Other compensation (including bonuses)

Prior Employer
Position Title
Supervisor Name
Supervisor Phone
May we contact employer?	Yes No
Date Employment Began
Date Employment Ended
Final Base Salary
Other Compensation (including bonuses)

Prior Employer
Position Title
Supervisor Name
Supervisor Phone
May we contact employer?	Yes No
Date Employment Began
Date Employment Ended
Final Base Salary
Other Compensation (including bonuses)

Educational Background

High School Name
City, State
Overall GPA (4.0 scale)
Received Diploma or GED?	Yes No

College Name
City, State
Concentration or Major
Overall GPA (4.0 scale)
Received Degree?
Degree

Other Educational Institution
City, State
Concentration or Major
Overall GPA (4.0 scale)
Received Degree/Certificate?	Yes No
Degree/Certificate

Other Educational Institution
City, State
Concentration or Major
Overall GPA (4.0 scale)
Received Degree/Certificate?	Yes No
Degree/Certificate

Resume

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Disclaimer

At-Will Employer: I understand that the Company is an “at-will” employer. I understand that my employment and compensation can be concluded, with or without cause, at any time at the option of either the Company or myself. I understand that no representative of the Company has the authority to enter into any agreement of employment for any specific period of time, or to make any agreement contrary to the foregoing. Subject to Applicable Federal Laws: I authorize the Company to seek information regarding my character, general reputation, previous employment and similar background information, and to contact any and all prior employers or other references I have listed on my application or otherwise prohibited. I also authorize any educational institutions to provide transcripts and confirm degree status. I release all parties and all persons connected with any such request for information from all claims, liabilities, and damages for any reason arising from furnishing such information. If employed, I release the Company from any liability for future references it may provide regarding work history at the Company. Certification to Work in the United States: I understand that as a condition of my employment, I must provide documentation to prove identity and eligibility to work in the United States by presenting any of the several documents as defined in the INS Regulation 8 CFR #27a.2(b)(1)(v). A complete list of all possible documents for proving eligibility to work is available in the office of the Director of Personnel. Accuracy of Information: I represent that I have carefully reviewed all of the above questions, and have taken all the time necessary to provide full, complete, and accurate responses. I understand that the Company will rely on the information I have provided on this application. I further represent that the information I have provided contains no errors, omissions, misrepresentations, or anything that could be construed as misleading. I understand that if employed, any errors, omissions, or misleading statements that I provided on this application or other documents related to my application, will be grounds for my dismissal. Select “I Agree” below if you agree with the above statements.
	I Agree