Personal Information

First Name:
Middle:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Are you a U.S. Citizen? Yes No
Are you 18 years or older? Yes No	If yes, are you 21 or older? Yes No

List employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities. If you have less than four places of employment, include personal references to be contacted. May we contact your present employer? Yes No

From Date mo/yr	To Date mo/yr	Employer Name, Address, Phone	Position Held	Supervisor	Start Wage	End Wage	List Major Duties

Education

	Name	Course of Study	Years Completed	Did You Graduate?	Degree
High School
College
Other (specify)

Availablility

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

Have you ever been convicted of a crime, excluding misdemeanors? Yes No    If Yes, explain:

Have you ever been bonded? Yes No    If Yes, by which employer(s)?:

Emergency Notification

This information is to facilitate contact in the event of an emergency and is not used in the selection process.
Full Name:
Address:
Phone:
Relationship:
Work Place:
Work Phone:

Fair Credit Reporting Act and Employment at Will Disclosure.

I understand I am applying for employment which can be terminated at will by either myself or AmeriStop Food Mart at any time and that nothing contained in any manual, brochure, or other AmeriStop Food Mart material shall constitute an implied contract for employment or continued employment. I also acknowledge that Ameristop Food Mart may request previous employment and/or background information to evaluate my qualification for employment. Upon written request, information as to the nature and scope of such report will be provided. I understand that false or incomplete information in this application for employment is grounds for dismissal and forfeiture of all related benefits. It is understood that, as a condition of initial or continued employment, I agree to submit to such lawful examinations, medical, substance abuse, or other as may be required by the Energy company. The company will pay the reasonable cost of any such examination which may be required. I certify that the information on this application is accurate and complete. If hired, I agree to complete a bonding application if requested by the insurance company, and in order to comply with Federal Employment Eligibility Verification Law will provide either ONE document from List A or ONE document from List B and ONE document from List C:

List A United States Passport Certificate of U.S. Citizenship Certificate of Naturalization Unexpired Foreign Passport with:  Employment Authorization  Alien Registration Card with Photo	List B Unexpired State-Issued Driver's License Unexpired State-Issued Identification Card School Identification Card Voter's Registration Card United States Military Card
List C Social Security Number Card (original) An Original and Certified Copy of:  Birth Certificate Issued by State  or County bearing an Official Seal	Persons under the age of 18 who are unable to present a document listed above may bring a: School Record or Report Card Clinic, Doctor or Hospital Record Daycare or Nursery School Record