Application for Employment

Central Iowa Lubrication

Jiffy Lube

Application for Employment

Federal law prohibits discrimination on the basis of race, color, religion, sex, national origin, age, disability, or other protected status.

PERSONAL DATA (Please Print)



First Middle Last


Street City State Zip

Phone:___________________________ SS #:_______________________ Drivers License #:_________________

State Licensed In:__________ Expiration Date:______________ Are you currently a valid driver? Yes No (circle one)

How did you hear about this position?_________________________ Are you 18 or older?________ If no, how old?___________

Can you prove you are legal to work in the U.S.?______________

If hired, are you able to get to work and meet attendance requirements every day?____________________________

Have you been convicted of a felony in the last 5 years?___________ If so, please explain____________________________

Complete the following schedule based on your availability:

Mon. Tues. Wed. Thurs. Fri. Sat. Sun.





Can you work overtime if required? _______ Weekends?_________ Please list hours you cannot work:________________

How many days of work or school have you missed in the last year for reasons other than sickness? ____________ Please

EDUCATION BACKGROUND (Please circle the highest level of education attained)

Elementary 1-5 Junior High 6 7 8 High School 9 10 11 12 GED Technical School (what field)______________

Military Education_______________________ College 1 2 3 4 College name and City___________________________

Degree earned_________________________________ Year____________

Are you currently in school?_________________ What year?______________________ Summarize any special skills you have that qualify you for the position you are applying for:_________________________________________________________________________________________________


EMPLOYMENT HISTORY (Please list your last 3 employers, starting with the most recent)

1. Employer Address Phone Job Title/Position


Supervisor’s Name & Title_____________________________ Reason or leaving ________________________

Describe Duties_______________________________________________________________________________

Starting Date____________ End Date___________ Starting Wage___________ Ending Wage_____________

2. Employer Address Phone Job Title/Position


Supervisor’s Name & Title____________________________ Reason for leaving___________________________

Describe Duties_______________________________________________________________________________

Starting Date___________ End Date____________ Starting Wage___________ Ending Wage_______________

3. Employer Address Phone Job Title/Position


Supervisor’s Name & Title___________________________ Reason for leaving_____________________________

Describe Duties________________________________________________________________________________

Starting Date___________ End Date_____________ Starting Wage __________ Ending Wage________________

Please explain any employment gaps found above_____________________________________________________

May we contact the employers listed above?_______ Please indicate any you do not wish us to contact_________


I certify that the statements herein are true and correct to the best of my knowledge, and I understand that any false statements or omissions by me on this application and any other required document is considered a cause for denial of employment or discharge, whenever discovered.

I understand that this document is an application for employment, and does not constitute an agreement or contract for employment of any length of time. If hired, I have the freedom to quit at any time. The employer also has the right to terminate my employment with or without cause, the exception being as required by law.

I authorize the above employer to investigate all information in the above application for employment. The employer has the right to contact previous employers, schools and other references to verify this information. I release the employer from any liability in gathering this information. I release from liability any companies or institutions supplying this information. After termination of my employment, for whatever reason, I release the above employer from liability for any information supplied to future potential employers.

Applicants Signature:_________________________________ Date:__________________