Application Form

To apply, please submit the application below:

*Required

Contact Information

First Name*
Middle Name
Last Name*
Email*
Phone*

Current Address

Address*
Address Line 2
City*
State*
Zip Code*

Previous Address

Address
Address Line 2
City
State
Zip Code

General Information

Have You Ever Used Any Other Names Other Than One Stated Above?
If Yes, List Names:
Are You 18 Years of Age or Older?
Are You Legally Authorized To Work In The United States?
Have You Ever Served In The U.S. Military?
Have You Ever Filled Out An Application With Us Before?
If Yes, Give Dates:
Have You Ever Been Employed With Us Before?
If Yes, Give Dates:
Position You Are Applying For:
Other Positions You Would Consider:
How Did You Become Aware Of Job Opening?
Date You Are Available To Begin Work:
Preferred Store Location:
Would You Be Willing To Work At Another Store Location If Necessary?
Type of Employment Desired:
Please give an overview of the days/hours you'd be available to work:
Do You Have Reliable Means Of Transportation To Enable You To Get To Work On Time?
Do You Have a Valid Driver’s License?
Driver’s License Number:
Have You Ever Been Suspended Or Discharged From Employment?
Are You Currently On Lay Off Status And Subject To Recall?
Have You Ever Been Convicted Of A Crime?
If Yes, Describe:
Have You Ever Been Arrested For A Felony?
If Yes, Describe:

(Conviction for a Felony or Misdemeanor Will Not Necessarily Be a Bar to Employment. Factors Such As Age and Time of the Offense, Seriousness and Nature of the Violation, And Rehabilitation Will Be Taken Into Account)

Job Responsibilities: Superior Customer Service & Attendance, Cash Register, Stocking, Cleaning, Flexible Schedule

Can You Meet the Attendance Requirements of the Position?
Can You Perform The Requirements Of The Job For Which You Are Applying For?

(Applicants Will Not Necessarily Be Disqualified If They Cannot Perform a Particular Job Duty)

If The Answer to the Above Question Is No, Please Identify the Duties Which You Are Unable To Perform:
You Are Not Required To Disclose Information About Physical Or Mental Limitations That You Believe Will Not Interfere With Your Capability To Do The Job. However, If You Desire The Company To Consider Special Arrangements To Accommodate A Physical Or Mental Impairment, You May Identify That Impairment And Suggest The Kind Of Accommodation That You Believe Would Be Appropriate:

Employment History Begin with Most Recent/Current Job

Employer 1

Business Name
Type of Business
Address
City
State
Zip Code
Phone
Name of Supervisor
Start Date
End Date
Starting Position
Final Position
List Duties Performed
Reason for leaving
May We Contact For Reference?

Employer 2

Business Name
Type of Business
Address
City
State
Zip Code
Phone
Name of Supervisor
Start Date
End Date
Starting Position
Final Position
List Duties Performed
Reason for leaving
May We Contact For Reference?

Employer 3

Business Name
Type of Business
Address
City
State
Zip Code
Phone
Name of Supervisor
Start Date
End Date
Starting Position
Final Position
List Duties Performed
Reason for leaving
May We Contact For Reference?

Education

High School

High School Name
Diploma

College/University

College Name
Years Completed
Course of Study:
Degree

Other

College Name
Years Completed
Course of Study:
Degree
Describe Any Other Training, Skills and Extra-Curricular Activities That Are Related To the Position for Which You Are Applying:
State Any Additional Information You Feel May Be Helpful To Us in Considering Your Application:

Personal References

Name:
Phone Number:
Name:
Phone Number:
Name:
Phone Number:

The facts set forth above are true, correct and complete. I hereby authorize investigation of all statements contained in this application and full disclosure of my present and prior work record. I grant permission to Lenawee Fuels, Inc. to obtain information concerning my general reputation, character, conduct, honesty, reliability, ability to take direction from supervisors, work quality, and other qualifications for employment. I hereby authorize any person or organization contacted to furnish information and opinions concerning any and all such matters, whether same as a matter of record or not. I understand that this may include a record of disciplinary action assessed by my previous employers. I hereby expressively waive my right to written notice from present or former employers whenever they disclose to Lenawee Fuels, Inc. a letter of reprimand, disciplinary report, disciplinary action or any other information concerning me. I hereby further release any such person or organization from any and all liability which may result in furnishing such information or opinion. I also release Lenawee Fuels, Inc. from any obligation to provide me with written notification of such disclosure. I understand that employment is contingent upon this investigation and, if employed, any false statement, misstatement, or omission of fact in this application shall result in my termination. I further understand and agree that if in the opinion of Lenawee Fuels Inc., the results of the investigation are unsatisfactory, that an offer of employment that has been made may be withdrawn or my employment with Lenawee Fuels Inc. may be terminated.

I further understand that Lenawee Fuels Inc. may require that I complete a health screening questionnaire and/or submit to a medical examination by a designated physician: (1) after I have received an offer of employment and prior to my commencement of employment duties; and, (2) during course of my employment as required by business necessity or for job related purposes. I hereby consent to such requirements and recognize that employment is contingent upon receipt of a satisfactory evaluation of my health condition. I further understand and agree that prior to commencing employment or after I am employed, I may be requested to submit to test that determine the presence of alcohol or illegal drugs. I further agree to the release of any such test results to Lenawee Fuels Inc., and agree that if I refuse such tests before commencing employment my offer of employment will be revoked, or if I refuse such tests after being employed, my employment will be terminated.

I agree this application is not an offer of employment. I agree that if I am employed by Lenawee Fuels Inc. (1) that my contract of employment is strictly at will and may be terminated at any time, with or without notice and with or without cause, at the option of either Lenawee Fuels Inc. or myself; (2) that I will receive wages and benefits and be subject to rules and regulations and that such wages, benefits, rules and regulations are subject to change by Lenawee Fuels Inc. at any time with or without notice to me; (3) that in partial consideration for my employment, I should not commence in any action or other illegal preceding relating to my employment or the termination there of more than six months after the event complained of and agree to waive any statute of limitations to the contrary (unless a shorter period is provided by law or Perky Pantry’s employment handbook or policies); (4) that might work hours may be modified by Lenawee Fuels Inc. and, if requested I will work overtime; (5) that this constitutes the entire agreement between Lenawee Fuels Inc. and myself and that any and all prior agreements are null and void, and that no oral or written representations made by anyone employed by Lenawee Fuels Inc., nor any document published by Lenawee Fuels Inc., either before or after this agreement, shall in anyway modify the above terms accept, except by written amendment to this agreement directed exclusively to me and signed by the President of Lenawee Fuels Inc. and me.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS AND CONDITIONS OF EMPLOYMENT
Please sign by typing your name:
Today's Date
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