LAST NAME       FIRST NAME       M. I.        PHONE NUMBER   

STREET       CITY      STATE        ZIP CODE 

SOCIAL SECURITY NUMBER                                        ARE YOU 18 YEARS OF AGE OR OLDER     YES NO

NAME/PHONE OF PERSON TO BE NOTIFIED IN CASE OF EMERGENCY 

CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING WITH OR WITHOUT ACCOMMODATIONS?       YES NO

IS YOU CITIZENSHIP OR IMMIGRATION STATUS SUCH THAT YOU CAN WORK IN THE US?          YES NO
IF HIRED, CONTINUED EMPLOYMENT MAY BE DEPENDENT UPON PROOF OF CITIZENSHIP OR PRESENTATION OF ALIEN REGISTRATION

HOW WERE YOU REFERRED TO DICKERSON STATIONS, INC?  WALK IN MAIL IN REHIRE AGENCY NEWSPAPER AD FRIEND RELATIVE OTHER

HAVE YOU EVER APPLIED WITH DICKERSON STATIONS, INC.?    YES NO      IF YES, WHERE/WHEN  

HAVE YOU EVER BEEN EMPLOYED BY DICKERSON STATIONS INC.?  YES NO    

IF YES, COMPANY NAME       LOCATION       DATE OF EMPLOYMENT 

IF YES, LIST NAMES            LOCATION 

                                                                               EDUCATION                                                                                    

JUNIOR HIGH                                                  

HIGH SCHOOL                                                 

TRADE COLLEGE                                                 

COLLEGE                                                   

OTHER                                                        

                                                                                 MILITARY                                                                                     

BRANCH OF SERVICE  ARMY NATIONAL GUARD NAVY AIR FORCE COAST GUARD MARINES          MONTHS OF DUTY       FROM (MO/YR)             TO (MO/YR)         

FINAL RANK          MAJOR DUTIES    

                                                                                  GENERAL                                                                                     

DATE AVAILABLE TO WORK       TYPE OF WORK YOU ARE SEEKING  PART-TIME FULL-TIME TEMPORARY

TYPE OF POSITION (MECHANIC, MANAGER, ETC.)  

DAYS AND HOURS AVAILABLE TO WORK

                       SUNDAY            MONDAY            TUESDAY            WEDNESDAY            THURSDAY            FRIDAY             SATURDAY

   FROM                                                                                             

      TO                                                                                                

WHAT INTERESTS YOU IN DICKERSON STATIONS, INC.?

WHAT ARE YOUR HOBBIES, SPECIAL INTERESTS, AND ACTIVITIES?   (DO NOT INCLUDE ANY INDICATING CREED, RACE, OR RELIGION)

HAVE YOU EVER BEEN CONVICTED OF A FELONY?         YES NO 

IF YES, STATE WHERE, WHEN, AND NATURE OF OFFENSE.   (INFORMATION REGARDING CONVICTION RECORD WILL NOT NECESSARILY BAR APPLICANT FROM EMPLOYMENT, BUT WILL BE REVIEWED IN LIGHT OF DUTIES RELATED TO JOB SOUGHT)

                                               EXPERIENCE (LIST LAST EMPLOYER FIRST)                                                       

EMPLOYER                 FROM (MO/YR)               TO (MO/YR)    

ADDRESS           CITY              STATE    

JOB TITLE         DUTIES    

REASON FOR LEAVING   

SUPERVISOR        PHONE NO:       EARNINGS     $   PER HOUR WEEK MONTH YEAR

WHERE YOU HIRED INTO THIS POSITION      YES NO       IF NO, EXPLAIN   

EMPLOYER                 FROM (MO/YR)               TO (MO/YR)    

ADDRESS           CITY              STATE    

JOB TITLE         DUTIES    

REASON FOR LEAVING   

SUPERVISOR        PHONE NO:       EARNINGS     $   PER HOUR WEEK MONTH YEAR

WHERE YOU HIRED INTO THIS POSITION      YES NO       IF NO, EXPLAIN   

EMPLOYER                 FROM (MO/YR)               TO (MO/YR)    

ADDRESS           CITY              STATE    

JOB TITLE         DUTIES    

REASON FOR LEAVING   

SUPERVISOR        PHONE NO:       EARNINGS     $   PER HOUR WEEK MONTH YEAR

WHERE YOU HIRED INTO THIS POSITION      YES NO       IF NO, EXPLAIN   

EMPLOYER                 FROM (MO/YR)               TO (MO/YR)    

ADDRESS           CITY              STATE    

JOB TITLE         DUTIES    

REASON FOR LEAVING   

SUPERVISOR        PHONE NO:       EARNINGS     $   PER HOUR WEEK MONTH YEAR

WHERE YOU HIRED INTO THIS POSITION      YES NO       IF NO, EXPLAIN   

EMPLOYER                 FROM (MO/YR)               TO (MO/YR)    

ADDRESS           CITY              STATE    

JOB TITLE         DUTIES    

REASON FOR LEAVING   

SUPERVISOR        PHONE NO:       EARNINGS     $   PER HOUR WEEK MONTH YEAR

WHERE YOU HIRED INTO THIS POSITION      YES NO       IF NO, EXPLAIN   

                                                                                REFERENCES                                                                                

LIST BELOW THREE INDIVIDUALS WHO HAVE KNOWN YOU FOR FIVE YEARS OR MORE

                            NAME                                                                               OCCUPATION                                                   ADDRESS/PHONE NO. 

                                                                           CERTIFICATION                                                                                

I certify that all answers and statements made by me herein and other information given by me pursuant to becoming employed by this company are, true, complete and correct and that I have not withheld any fact that would if disclosed, affect my application unfavorably.  I understand that if I withhold information that would, if disclosed, affect my application unfavorably or provide false, incomplete or misleading information, this application may be rejected or I may be dismissed if already employed by the company.  If further certify that I understand that as part of the procedure in processing this application, there may include information obtained through interviews with me and third parties, such as family members, former employers, friends, neighbors, or others with whom I am acquainted.

     I understand that the employment of any employee can be terminated with or without cause, at any time, at the option of either company or the employee.  No employee, representative, manager, official or supervisor of the company other than the Vice President, Corporate Relations & Services, has any authority to enter into any agreement for employment for a specified period of time or make any agreement relative to employment that is contrary to the foregoing.

    
Applicants Name*                                           Date

*  By entering your name in this box you are providing a digital signature.  This digital signature is as
legal and binding as your written signature.

DICKERSON STATIONS, INC. IS AN EQUAL OPPORTUNITY EMPLOYER