Jiffy Mart - Apply Today

A value is required. First Name* A value is required. M.I.* A value is required. First Name* A value is required. Phone*
A value is required. Street Address* A value is required. City* State A value is required. Zip* A value is required. Years at this address*
Previous Street Address Previous City Previous State Previous Zip Years at this address

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Position Appplying For*

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Expected Pay*

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Date Available to Work*

Referred By

State All Hours Available to Work:

Sunday*
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Monday*
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Tuesday*
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Wednesday*
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Thursday*
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Friday*
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Saturday*
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Do you have a relative employed by Tevis Oil, Jiffy Mart, or Modern Comfort: Yes No

If yes, who and what location?:

Have you ever been employed by Tevis Oil, Jiffy Mart, or Modern Comfort: Yes No

If yes, when and where?:

**During the past 7 years, were you convicted of a crime, excluding misdemeanors, and traffic violations: Yes No
(You are not required to disclose convictions that have been expunged)

If convicted, please describe:

Are you a U.S. Citizen/Resident? Yes No

Are you eligible to work in the United States? Yes No

Do you have transportation to work? Yes No

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High School/College*

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City*

State

Yes No
Did you Graduate?

Degree Courses

Average Grade

Graduate School/Other

City

State

Yes No
Did you Graduate?

Degree Courses

Average Grade

Employer

Address

Job Title

Name/Phone of Supervisor

Salary

Date Started

Date Ended

Description of Duties

Reason for Leaving

Yes No
May we contact?

Employer

Address

Job Title

Name/Phone of Supervisor

Salary

Date Started

Date Ended

Description of Duties

Reason for Leaving

Yes No
May we contact?

Branch of Service

Date Entered

Date Discharged

Do you have service related skills and experience applicable to civilian employment? Yes No

Describe:

What additional relevant experience or training have you had
other than your work experience, military service and education?:

Name/ phone of person to contact in case of accident/ injury:

Please make a selection. I authorize investigation of all statements contained in this application. I understand that misrepresenting or omission of facts called for is a cause for dismissal. I authorize the references listed above to provide any information concerning my previous employment, and release all parties from all liability by furnishing this information. I understand that as part of the processing procedure from my employment application, An investigate report may be made concerning character, general reputation, personal characteristics and mode of living. I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without notice.

* Required ** A conviction will not necessarily bar you from employment.