Employment Application
Fill the form below accurately indicating your potentials and suitability to job applying for.
Name
*
First Name
Last Name
Birth Date
*
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Year
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Do you have the legal right to live and work in the USA?
*
Please Select
YES
NO
State Alcohol Beverage Control Boards require a minimum age to sell alcoholic beverages; select the age section that applies to you.
*
Please Select
Under 18 years old
18-20 Years Old
21 and over
Position desired?
*
Location desired?
*
What type of employment are you seeking?
*
Please Select
Part Time
Full Time
Temporary
Any
Desired Hourly Pay
*
Date Available To Start?
*
Employees may be required to work hours other than those preferred or assigned. Are you restricted on the hours and days you are available for work?
*
Please Select
Yes
No
If "YES" please explain
Have you ever worked for Lipscomb Oil Co. or Parker's Filling Station stores before?
*
Please Select
Yes
No
Are you related to anyone employed by Lipscomb Oil Co.?
*
Please Select
Yes
No
If "YES" which store?
Do you have reliable transportation to work as scheduled?
*
Please Select
Yes
No
Is there any reason you cannot regularly report to work?
*
Please Select
Yes
No
If "YES" please explain
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Reading small numbers and letters is an essential job requirement. Do you have any problems with your vision that would prevent this
*
Please Select
Yes
No
If "YES" please explain
Lifting of items up to 50 lbs is an essential job requirement. Are you able to do so?
*
Please Select
Yes
No
Constant physical activity (assisting customers, stocking shelves, cleaning store and property, etc) is an essential job requirement. Are you able to be physically active the entire shift?
*
Please Select
Yes
No
Are you presently using alcohol and/or non-prescription narcotics?
*
Please Select
Yes
No
If "YES" please explain
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Employement History
Please give accurate and complete information, (full-time and part-time). Start with the most recent job and go back to your first job. Include any Armed Forces duty (dates and branch only).
Employer Name
*
Starting Wage
*
Ending Wage
*
Job Title
*
Type Of Employment
Please Select
Part Time
Full Time
Type Of Employment
Please Select
Part Time
Full Time
Supervisors Name
*
First Name
Last Name
Supervisors Phone Number
*
Please enter a valid phone number.
Your Primary Duties
*
Reason For Leaving
*
May we contact this employer?
Please Select
Yes
No
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Employer Name
Starting Wage
Ending Wage
Job Title
Type Of Employment
Please Select
Part Time
Full Time
Supervisors Name
First Name
Last Name
Supervisors Phone Number
Please enter a valid phone number.
Your Primary Duties
Reason For Leaving
May we contact this employer?
Please Select
Yes
No
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Education
Please provide us with all of your schooling going back to Elementary School.
Elementary School Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Graduated?
*
Please Select
Yes
No
High School Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Graduated?
*
Please Select
Yes
No
College/Trade School Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Graduated?
Please Select
Yes
No
Highest Certificate Achieved
Please Select
Certificate of Completion
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
Please list any special skills and qualifications you have that may qualify you for the applied position:
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Security
List all convictions for breaking the law you have received in the last 7 years (include misdemeanor convictions). Also List any felony convictions you have received in your adult lifetime. Note: Convictions are not necessarily a bar to employment; however, deception as to their existence or falsification of the exact nature will result in denial or termination of employment. Factors such as the time of offense, seriousness and nature of the violation, and rehabilitation will be taken into consideration.
Do you have any convictions to report?
Please Select
None
One
Two
Three
Four or more
Date of Conviction
Convicted Of What?
Court Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Conviction
Convicted Of What?
Court Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Conviction
Convicted Of What?
Court Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Disclosures
Please Read Carefully and Electronically Sign that you Understand and Accept the Following Information:
Application for Employment and Agreement of Employment to and with Lipscomb Oil Co., Inc. and/or its Subsidiary Companies Unconditional Release
Equal Opportunity Employer M/FI agree to comply with all rules of Lipscomb Oil Co., Inc. I hereby affirm and declare that all the foregoing statements are true and correct. The information provided in this application is true, and correct.I hereby authorize Lipscomb Oil Co., Inc. to conduct any investigation it deems necessary with respect to information set forth on this application. I also hereby authorize Lipscomb Oil Co., Inc., except as prohibited by law, to release such information together with their opinions on these matters without any liability for any damage whatsoever caused either directly or indirectly by giving or receiving such information or opinions. I authorize any former of present employer; schools, colleges, and universities; utility companies; credit, finance bureau offices, personal references and/or any other person or persons, to give any information they have concerning my character, credit and employment record. I hereby unconditionally release any named or unnamed informant from any and all liability resulting from the furnishings of this information.I hereby authorize the Chief of Police, and/or any and all members of any Police Department in any local areas where I have lived and/or worked; or any other concerned law enforcement agency, to furnish any information they may have concerning me which they have on record or otherwise. I hereby release the Chief of Police and/or any and all members of the aforesaid Police Department and any other law enforcement agency wherever situated, from any and all liability resulting from the furnishing of this information. It is understood that any false statement or omission on this application may be considered as sufficient cause for rejection of this application, or dismissal, if already employed by Lipscomb Oil Co., Inc.I UNDERSTAND THAT NOTHING CONTAINED IN ANY OF LIPSCOMB OIL CO., INC'S POLICY, SAFETY, AND PROCEDURES, AND NOTHING SAID TO ME BY ANY REPRESENTATIVE OF LIPSCOMB OIL CO., INC. SHALL BE DEEMED TO CREATE ANY CONTRACT OF EMPLOYMENT BETWEEN ME AND LIPSCOMB OIL CO., INC. AND THAT MY EMPLOYMENT MAY BE TERMINATED BY ME OF LIPSCOMB OIL CO., INC. AT ANY TIME FOR ANY REASON WITHOUT ADVVANCE ONE TO THE OTHER. I UNDERSTAND THAT LIPSCOMB OIL CO., INC. MAY DRUG TEST ME. LIPSCOMB OIL CO., INC. IS A DRUG FREE ENVIRONMENT.As a part of our review of your application, and in reliance upon your waiver of any confidentiality, we may request or compile an investigative consumer report including information as to your character. If so, you are entitled to a copy of any such report upon written request. Public Law 91-508.
Pre-Employment Drug/Alcohol Testing Consent and Release
I hereby consent to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis, as shall be determined by Lipscomb Oil Company (Company) in order to meet with their policy regarding the selection of applicants for employment.I further authorize and give full permission to have the Company and/or its authorized agents and physicians to send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company. I further agree to and hereby authorize the release of the results of said tests to the Company.I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.I further agree to hold harmless the Company and its agents and physicians from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection with the Company's consideration of my application of employment.I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
Acknowledgement of At-Will Employment
I hereby understand and expressly agree that by applying for a position with Lipscomb Oil Company (Company), and if I am eventually employed by the Company, that my employment is at-will, and that I may terminate my employment, and the Company may terminate my employment, with or without notice and with or without cause, at any time.I acknowledge that no one other than the President of the Company has the authority to alter this at-will employment arrangement or enter into an employment agreement for a specific amount of time. Any such agreement must be in writing, and signed, by the President.
Anti-Discrimination Policy
LIPSCOMB OIL COMPANY strives to provide equal employment opportunities for any employee or applicant for employment because of race, color, religion, age, sex, national origin or ancestry, marital status, or family or family responsibilities, veteran's status, or disability in accordance with applicable federal, state, and local law.If you believe you have been discriminated against, you must report the act of discrimination to the Store Manager or District Manager, immediately. If you feel uncomfortable doing so or if your supervisor is the source of the problem, condones the problem, or ignores the problem, report to the Operations Manager.If you believe you have been discriminated against in the application process, you must report the act of discrimination to the Operations Manager immediately.
Your Signature- You have read and understand the four disclosures above
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