Application For Employment - Jiffy Lube Page 2

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EMPLOYMENT HISTORY
Please list your last four employers, starting with the most recent.
1. Employer
Address
Phone
Job Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
2. Employer
Address
Phone
Job Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
3. Employer
Address
Phone
Job Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
4. Employer
Address
Phone
Job Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
Please explain any employment gaps found above:___________________________________________
May we contact the employers listed above?____ If there are any you don’t wish us to contact, please list:
____________________________________________________________________________________
I hereby certify that my answers and assertions set forth in this application are true and complete to the
best of my knowledge. If I am employed, I understand that any false statements on this application shall be
considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of
my prior educational and employment history.
Furthermore I understand that if I am hired, employment with this company is "at will," which means that
either the company or I can terminate my employment for any reason not prohibited by state or federal law.
After termination of my employment, for whatever reason, I release the above employer from liability for
any information supplied to future potential employers.
Signature: ___________________________________________
Date: _____________________
Please drop this application off at the Jiffy lube where you are applying for work.

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