Non-Driver Employment Application

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POWERS OIL COMPANY LTD. Dba Powers Oil & Propane NON-DRIVER EMPLOYMENT APPLICATION

1. Employer Information

Employer: Powers Oil Ltd. Address: 1681 West Main St. Telephone: 330-821-8387 City/State/ZIP: Alliance, Ohio 44601

2. Applicant Information

Applicant Name(Required)

First Last

Applicant Email(Required)

Applicant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years at this Address(Required)

(If less than 3 years provide additional addresses)

Additional Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone(Required)

Evening Phone

Driver's License(Required)

(State, Number, Expiration)

3. Emergency Contact

Emergency Contact Name(Required)

First Last

Relationship to you(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone(Required)

Evening Phone

4. Job Position Applied For

Desired Salary(Required)

Who referred you to our company?

Have you been a licensed driver for at least 5 years?(Required)

Yes

If applicable, are you able to work overtime?(Required)

Yes

If offered employment, when would you be available to begin work?(Required)

Are you legally eligible for employment in the United States?(Required)

Yes

Are you able to perform the essential functions of the job for which you are applying with reasonable accommodations, including those that require moderate to heavy lifting?(Required)

Yes

Have you ever been convicted of any crime, including traffic violations?(Required)

Yes

Please describe (include min. past 3 yrs., date of conviction, offense, location, type of motor vehicle operated)

Have you ever been involved in any traffic accidents/crashes?(Required)

Yes

Please describe (include min. past 3 yrs., nature of accident, and if any fatalities or personal injuries resulted

Have you ever had a denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle?(Required)

Yes

Please describe in detail the facts and circumstances of such denial, suspension or revocation

5. Applicant's Skills and Qualifications

Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Please select from the following abilities or skills that apply:

Mechanical Experience

Customer Service

Driving Experience

CDL/Hazmat License

Did you graduate from High School?(Required)

Yes

Did you receive your GED?(Required)

Yes

High School/GED Name and Address

Did you attend College/University?(Required)

Yes

Did you receive a degree?(Required)

Yes

Degree Field

Other Training

Awards, Honors, Special Achievements

Military Service

Yes

Branch

Specialized Training

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.   I understand that the information submitted on this application will be used for the purpose of investigating the applicant’s background, including contacting the applicant’s prior employers and obtaining the applicant’s driving record as well as driving performance history for the preceding three years for each DOT regulated employer as well as the state or appropriate agency for which a motor vehicle operator’s license is held. I authorize Powers Oil Ltd to contact former employers, the State and/or appropriate agency, as well as educational organizations regarding my employment, driving record, driving safety performance history and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. I understand that as a part of the Hazardous Materials Endorsement Threat Assessment Program, the TSA implemented on January 31, 2005 and Powers Oil Ltd. dba Powers Oil and Propane’s driver qualification policy a criminal background check will be conducted at the time of hire and as needed in the future to meet the company’s security plan and Hazardous Materials Endorsement compliance. I authorize Powers Oil Ltd. to conduct a criminal background check both now and in the future.   If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Owner, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Powers Oil Ltd, except in a specific written contract of employment signed on behalf of the organization by its Owner, has the power to alter or vary the voluntary nature of the employment relationship.   I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. 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.

Name(Required)

First Last

Signature(Required)

Date(Required)

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