Applicant Information

Full Name:

Date:

Last

First

M.I.

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Phone:

E-mail Address:

Date Available:

Desired Pay Range:

Position Applied for:

Location Applying at:

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

Have you ever worked for this company?

If yes, when?

Are you 18 years of age or older?

Have you ever been convicted of a felony?

If yes, explain:

Please list the start/end times that you are available to work, and indicate whether you are available to work overnight.

Note: Availability may not change within the first 90 days of employment, and is subject to approval thereafter.

All applicants are subject to pre-employment, post-accident, and reasonable cause drug testing.

Education

High School:

Address:

From:

To:

Did you graduate?

Degree:

College:

Address:

From:

To:

Did you graduate?

Degree:

Other:

Address:

From:

To:

Did you graduate?

Degree:

References

Please list three professional references.

Full Name:

Relationship:

Company:

Phone:

Address:

Full Name:

Relationship:

Company:

Phone:

Address:

Full Name:

Relationship:

Company:

Phone:

Address:

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Disclaimer and Signature

I authorize The Hub Convenience Stores, Inc and/or Schlotzsky's of Dickinson, LLC to make any investigation on my personal or employment history and authorize any former employer, person, firm, corporation, or government agency to give The Hub Convenience Stores, Inc. any information they may have regarding me. In consideration of The Hub Convenience Stores, Inc. and/or Schlotzsky's of Dickinson, LLC review of this application, I release The Hub Convenience Stores, Inc. and/or Schlotzsky's of Dickinson, LLC and all providers of information from any liability as a result of furnishing and receiving this information. I also hereby declare that all of the above information provided by me to The Hub Convenience Stores, Inc and/or Schlotzsky's of Dickinson, LLC. is true, correct, and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I understand that my final acceptance for employment is dependent on my being able to perform the duties of the job for which I am applying and upon receipt of favorable reports on my qualifications. I understand that receipt of this application by The Hub Convenience Stores, Inc. and/or Schlotzsky's of Dickinson, LLC in no way implies that I will be employed. I understand and acknowledge that if I am employed by The Hub Convenience Stores, Inc. and/or Schlotzsky's of Dickinson, LLC, the continuation of my employment will solely be at the discretion of the company. I also understand that the company's policies, practices, benefit programs, and other terms and conditions of my employment are subject to revision or termination, at the discretion of the company. I understand that this application is not a contract of employment. I also understand that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the company is terminable-at-will so that both the company and I remain free to end our work relationship at any time with or without reason.

Signature:

Date: