JBC Inc. Petroleum Distrubutors Leasor Program and Employment Opportunities

May 20, 2012
Position(s) applied for :
Your Name :	Last Name	First Name	Middle Name	Social Security
Address :	Street			Phone
	City	State	Zip Code	How Long?

Previous Addresses :
Street	City	State	Zip Code	How Long?
Street	City	State	Zip Code	How Long?
Street	City	State	Zip Code	How Long?

Do you have the legal right to work in the United States?
Birth Date : YYYY-MM-DD		Can you provide proof of age?

Have you worked for JBC before?		Where?
Position :
Dates : MM-YYYY	From :	To :	Rate of Pay :
Reason for Leaving :

Are you now employed?		If not, how long since last employment?
Who referred you?			Rate of Pay expected :
Is there any reason you might be unable to perform the functions of the job for which you have applied?
If yes, explain if you wish. :

EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.) *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Employer 1			Date : MM-YYYY
Name :			From :	To :
Address :			Position :
City : State : Zip :			Wage :
Contact Person :			Phone :
Reason for Leaving :

Employer 2			Date : MM-YYYY
Name :			From :	To :
Address :			Position :
City : State : Zip :			Wage :
Contact Person :			Phone :
Reason for Leaving :

Employer 3			Date : MM-YYYY
Name :			From :	To :
Address :			Position :
City : State : Zip :			Wage :
Contact Person :			Phone :
Reason for Leaving :

Employer 4			Date : MM-YYYY
Name :			From :	To :
Address :			Position :
City : State : Zip :			Wage :
Contact Person :			Phone :
Reason for Leaving :

Employer 5			Date : MM-YYYY
Name :			From :	To :
Address :			Position :
City : State : Zip :			Wage :
Contact Person :			Phone :
Reason for Leaving :

EDUCATION
HIGHEST GRADE OR YEAR COMPLETED :		Grade School :	High School :	College :
Last School Attended :	Name :		City, ST :

EXPERIENCE AND QUALIFICATIONS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU IN YOUR DAILY DUTIES

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL PROGRAMS OR TECHNICAL MATERIALS YOU CAN WORK WITH (other than those already shown)


TO BE READ AND SIGNED BY APPLICANT This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. My email address serves as a temporary signature pending employment. I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
Applicant’s Name : Email Address :