Want to Work at a Refuel?

Employment Application

You must complete all sections of the application that apply to you. It is policy and practice of Refuel, Inc. to provide equal employment opportunity to all qualified applicants without regard to race, color, religion, creed, gender, age, national origin, veteran status, disability or any other criteria deemed unlawful under any applicable laws.

Personal Data
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Telephone Number*
Date Available

Education
College
Name and Location Course of Study #Yrs. Attended Did you graduate? Degree or Diploma?
High School
Name and Location Course of Study #Yrs. Attended Did you graduate? Degree or Diploma?
Other
Name and Location Course of Study #Yrs. Attended Did you graduate? Degree or Diploma?
U.S. Military Service
Branch of U.S. Military Service:
From
To

Employment History
List all employment starting with most recent job first. Attach an additional sheet if needed. Explain fully any gaps in your employment history. Be sure to account for all periods of time including military service and any period of unemployment.
1
From
To
Present or most recent employer
Telephone
Address
Street Address City State ZIP Code
Starting Pay
Final Pay
Name of Final Supervisor and Position
Your Job Title
Reason for leaving
2
From
To
Present or most recent employer
Telephone
Address
Street Address City State ZIP Code
Starting Pay
Final Pay
Name of Final Supervisor and Position
Your Job Title
Reason for leaving
3
From
To
Present or most recent employer
Telephone
Address
Street Address City State ZIP Code
Starting Pay
Final Pay
Name of Final Supervisor and Position
Your Job Title
Reason for leaving
May we contact all the employers shown?
- YES
- NO
List which ones and explain
Have you ever been involuntarily terminated, asked to resign or resigned in lieu of termination?
- NO
- YES
Explain your termination

Additional Information
Have you ever been convicted of or pled guilty or "no contest" to a felony or a misdemeanor other than a minor traffic offense? Refuel conducts background checks.
- NO
- YES
(Conviction of a felony or misdemeanor will not automatically disqualify you from consideration for employment.)
List date, city, charge and disposition
Date City Charge Disposition

Affidavit
(Please read before signing)

I authorize the company to make whatever inquiries necessary in connection with my application for employment. I understand that such inquiries may include information as to my character, general reputation, personal characteristics, creditworthiness, credit standing, credit capacity and mode of living.

I agree to release and hold harmless any employer, school, credit bureau, personal reference, law enforcement agency or utility company from any liability arising from the release of such information which I hereby authorize.

Statements I made in the application are true and complete. I understand that, if in any Company's judgment, I have made any false statement, omission, concealment, misrepresentation, or have failed to answer any question fully and accurately or results of such investigation are not satisfactory, any offer of employment may be withdrawn or my employment with the Company may be terminated immediately.

I agree to conform to Compnay rules and regulations and understand that neither my application for employment nor any other Company policy or document or verbal representation creates a contract of employment or limits these termination rights.

I further understand that no Company representative has any authority to enter into any agreement of employment unless such agreement is in writing and signed by the Company President. The Company is a drug-free workplace. I understand that I may be required to take a medical examination and pass a drug test at the Company's expense as a condition of employment.
Signature of Applicant*
Date*
Comments
This field is for validation purposes and should be left unchanged.

Employment

Employment Application

Step 1 of 6

Personal Data

Education

U.S. Military Service

Employment History

1

2

3

Additional Information

Affidavit