Susser Family Of Companies Application Employment Form – Fill Out and Use This PDF

Susser Family of Companies

Application for Employment

“Company” as used in this application means any of Stripes LLC, Susser Petroleum Company LLC, GoPetro Transport LLC, Town & Country Food Stores, Inc., T&C Wholesale, Inc., Susser Financial Services LLC and Applied Petroleum Technologies in their capacity as the potential employer of the person submitting this application.

Please complete all requested information.
Resumes will not be accepted in place of a completed application.				Date of Application:
Last Name		First Name	Middle Name
Present Address (Include City, County, State and Zip Code)
Length of time at this address					Phone Number (Including Area Code)

STATEMENT AND AUTHORIZATION TO RELEASE INFORMATION

PLEASE READ THIS STATEMENT CAREFULLY BEFORE YOU COMPLETE THIS APPLICATION

I understand that the Company, in considering my application for employment or any subsequent changes such as promotion or transfer, may verify the information set forth on this application and obtain additional information relating to my background. I authorize all persons, schools, companies,

corporations, credit bureaus, government agencies and medical personnel to supply any information relating to my background which may include, but is not limited to, criminal, credit and driver’s license, provided state law permits, and where such inquiries are job-related. I further agree to submit to

alcohol and/or drug screening tests, if requested of me, at any time prior to, or during, my employment in accordance with the law. I understand that no one, other than the President of the Company, in writing, has any authority to enter into terms of employment which differ from the terms contained herein and that my employment is at-will and can be terminated at any time without cause.

Have you ever applied for employment with our Company? ___ Yes ___ No. If yes, month and year ______ location

Where did you hear about employment with Susser Holdings? ___ Newspaper Ad ___ Worksource Center ___ Career Fair

___ Family/Friend ___ Company Website/Internet	___ Store Flyer ___ Other ______________________________________
Have you worked for us before? ___ Yes ___ No.	If yes, please indicate dates worked and location _______________________

Have you ever been known by another name? ___ Yes ___ No. If yes, by what name?

Do you have any relatives working for us? ___ Yes ___ No. If yes, answer the following:

Name

Position

Relationship

Only U.S. citizens or aliens who have a legal right to work in the United States are eligible for employment. Can you, upon employment, submit documentation verifying your identify and your legal right to work in the United States? ___ Yes ___ No

DO NOT ANSWER THE FOLLOWING QUESTION IF YOUR STATE PROHIBITS SUCH DISCLOSURE. A record or conviction does not necessarily disqualify you from employment consideration. Have you ever been convicted of a felony or misdemeanor, other than minor traffic violations? ___ Yes ___ No. If yes, list only conviction(s) and any explanation you wish to offer:

Position for which you are applying __________________ Salary expected ___________ Date Available for Work ____________

___ Full-Time ___ Regular ___ Part-Time ___ Temporary

With regard to initial work location, do you have any geographic preferences? ___ Yes ___ No. If yes, specify location __________

Are you willing to travel? ___ Yes ___ No. If yes, what percentage? __________________

Certain positions may require use of a motorized vehicle (car, van, truck). If use of such a vehicle is required in the job for which you are applying, do you have transportation? ___ Yes ___ No

Are you over the minimum age for selling alcoholic beverages in this state? ___ Yes ___ No

Have you reviewed the job description/specifications for the position for which you are applying? ___ Yes ___ No Do you understand the job requirements? ___ Yes ___ No

Can you perform the physical requirements of the job with or without reasonable accommodation? ___ Yes ___ No

Stripes stores are open 24 hours a day, seven days a week. Are you willing to work any day, shift or hours assigned by your supervisor? ___ Yes ___ No

Will you work overtime if directed to do so? ___ Yes ___ No

Revised January 2008

If you did not graduate from High School, circle last year completed in school			5	6	7	8	9	10	11
Name and Location of	Graduate		Type of Degree					Major Area
School(s) Attended	(Yes/No)			Awarded				of Study
High School
College
Other

List any other education, specialized training/skills, or certificates/licenses that you have that might relate to this job.

Please list ALL JOBS you have held for the past seven years, beginning with your present or last employer. Account for ALL time periods, including UNEMPLOYMENT, SELF-EMPLOYMENT, SCHOOL and U.S. MILITARY SERVICE. If space is insufficient, list on a separate page or on an additional application form.

Company Name (or period of unemployment) Address

Telephone Number			Supervisor
Employment: From __________ To __________			Position Held
	(mo./yr.)	(mo./yr.)

Salary: Start ___________ Final ___________ Based on ___ weekly ___ every two weeks ___ monthly ___ yearly

Are you eligible for reemployment? ___ Yes ___ No Reason for leaving

Company Name (or period of unemployment) Address

Telephone Number			Supervisor
Employment: From __________ To __________			Position Held
	(mo./yr.)	(mo./yr.)

Salary: Start ___________ Final ___________ Based on ___ weekly ___ every two weeks ___ monthly ___ yearly

Are you eligible for reemployment? ___ Yes ___ No Reason for leaving

Company Name (or period of unemployment) Address

Telephone Number			Supervisor
Employment: From __________ To __________			Position Held
	(mo./yr.)	(mo./yr.)

Salary: Start ___________ Final ___________ Based on ___ weekly ___ every two weeks ___ monthly ___ yearly

Are you eligible for reemployment? ___ Yes ___ No Reason for leaving

Company Name (or period of unemployment) Address

Telephone Number			Supervisor
Employment: From __________ To __________			Position Held
	(mo./yr.)	(mo./yr.)

Salary: Start ___________ Final ___________ Based on ___ weekly ___ every two weeks ___ monthly ___ yearly

Are you eligible for reemployment? ___ Yes ___ No Reason for leaving

May we contact your current employer?

Revised January 2008

As acknowledged by my signature below, I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsifications or intentional omissions in this application are grounds for disqualification from

employment consideration or for my dismissal from the Company. I agree to conform to the rules and regulations of the Company. I understand that this is not a contract and, if hired, I will be an “at will” employee and my employment and compensation can be

terminated with or without cause or notice, at the option of either the Company or myself. I further understand that no personnel recruiter, store manager or interviewer or any other representative of the Company other than in writing by the President of the Company has any authority to enter into any agreement with me for employment which differs from the foregoing.

Signature of Applicant

Date

AGREEMENT TO ARBITRATE

I understand that to be considered an applicant for employment by the Company I must first agree to arbitrate any and all claims that may arise out of my candidacy for and/or employment by the Company except for complaints relating to criminal conduct and proceedings and claims for unemployment compensation. I agree to arbitrate under the Susser Holdings, L.L.C. and Affiliates Arbitration Policy and Procedures (a copy of which I have been provided), in exchange for the Company considering this employment application and agreeing to also be bound by the Arbitration Policy and Procedures, any and all claims, disputes or controversies that exist now or arise later between me and the Company or between me and any Company employees, officers, members, owners or affiliated companies, including claims, disputes and controversies arising before, during and after my employment, if any, with the Company. By way of example only, such claims include, but are not limited to, claims under federal, state, and local statutory or common law, the law of contract or tort, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, the Americans with Disabilities Act, and claims for bodily injury or physical, mental or psychological injury without regard to whether such injury was sustained in the course and scope of employment. I have signed this agreement voluntarily and of my own free will. I understand that this arbitration agreement does not create a contract of employment, and that if I am hired, I will be an employee at-will subject to termination at any time without cause.

SignatureDate

CONSENT AND RELEASE FOR ALCOHOL AND DRUG TESTING

I, _____________________________________, being an applicant for employment by the Company hereby understand and

acknowledge that the Company operates a drug-free work environment and, therefore, reserves the right to require that I submit to a drug and alcohol test before I am formally hired. I also understand that such drug and alcohol testing will consist of the taking of urine, or any other medically recognized test designed to detect traceable amounts of drugs or alcohol in the body. I further understand

that if such testing indicates the presence of alcohol, non-prescribed or illegal drugs in my body in any detectable amount, and the presence of such drugs or alcohol is confirmed in a second test, the Company’s offer of employment will be

automatically withdrawn. I hereby give my consent to the Company to administer any or all of the above drug and alcohol testing procedures to me, and to review the results thereof.

I further understand that the purpose of this analysis is to determine or rule out the presence of alcohol or non-prescribed controlled substances in my urine. I hereby freely and voluntarily consent to this request and agree to participate in the testing program. I hereby release the Company, its employees, agents and contractors from any and all liability whatsoever arising from this request to be tested, the testing, and decisions made concerning my application for employment based upon the results of the testing. I agree to cooperate in all aspects of the testing program. I further acknowledge that the Company has provided me with an opportunity to ask questions related to its drug and alcohol testing program and all my inquiries have been answered.

I HEREBY AUTHORIZE THE ALCOHOL/DRUG TEST RESULTS BE RELEASED TO THE COMPANY.

Signature

Date

I understand that this application will remain active for one year from today’s date. If I still desire a position with the Company after this application expires, it will be my responsibility to fill out a new application and file it with the Company to keep my request for employment current.

Revised January 2008

* * * * * * FOR OFFICE USE ONLY * * * * * *

1)	Employment application completed and signed.	___ Yes	___ No
2)	Interview conducted.	___ Yes	___ No
3)	Telephone reference checks made.	___ Yes	___ No
4)	Pre-employment drug screening completed.	___ Yes	___ No
5)	Job description/specifications reviewed by applicant.	___ Yes	___ No
6)	Accommodation requested.	___ Yes	___ No

Comments:

Interviewed by __________________________________ Date _____________

Site Location ______________________________________________________

Date of Hire _____________________ Rate of Pay ______________________

Mail completed application to:

Human Resources

Susser Holdings, L.L.C.

4525 Ayers Street

Corpus Christi, Texas 78415-1401

Revised January 2008