Employment Application

Date

Name (Last / First / Middle Initial)

Phone Number

Street Address

State

Position Desired

Date Available for Work

Are you over the age of 21? YesNo


Personal References

Name

Name

Name

General Information

List your outside activities

Have you ever been convicted of a felony? YesNo

Have you ever been refused a fidelity bond? YesNo

Do you have any restrictions for lifting? YesNo

Educational History

High School

Name and Location

College

Name and Location

Other

Name and Location



Have you ever been employed by Black Diamond or Riggs Oil Company? YesNo


Have you ever been discharged from
any position? YesNo

Indicate any of the above that you prefer not to be contacted

Work History

Start with present or more recent position

Company Name & Address

Date (Month & Year)

Position Held, Duties & Last Wages

Immediate Supervisor & Phone Number

Reason for Leaving

May we verify all information YesNo

Indicate any of the above that you prefer not to be contacted

Notice

All applicants for positions with this company must be willing to consent to Pre-and Post-Employment Medical drug and chemical testing. Some chemicals or drugs can be detected up to ninety (90) days after use. Pre-employment medical exams may also be performed.

This company provides adequate Worker’s Compensation for legitimate on the job injuries. However, all claims will be thoroughly checked by the issuing insurance company’s inspectors and investigators. To avoid possible injuries to employees, every employee is required to use a hand truck or other similar equipment when carrying or lifting any merchandise or other object or objects or inventory while on duty. All accidents or suspected injuries must be reported to your manager or supervisor or home office immediately. An accident or injury report must be filed immediately with your location or the home office.

It is our policy to grant equal employment opportunities to all qualified persons without regard to race, creed, age, sex, religion, national origin or disability.

In consideration of my employment, I agree to conform to the rules and regulations of the company, the Commonwealth of Virginia and the United States of America. My employment and compensation may be terminated, with or without cause, and with or without notice, at any time, at the option of the company. I understand that the company would prefer a two weeks notice if I intend to leave employment.

I understand that I am only making application for employment and that filling out this form does not indicate that there is a position open and does not obligate the company to hire. By signing this form I attest that all information given is true and accurate to the best of my knowledge. I understand that any false information, omission, or misrepresentation on this form is cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the company. I understand that if I am convicted of a felony while employed that I am to immediately notify my manager, supervisor or home office. I understand that if I am hired, I will be required to present documented proof of identity and eligibility to work in the United States. Within three days of hire as set forth by the Immigration and Control Act of 1986.

I understand and attest that by checking the box below, it allows Black Diamond, former employers and references to verify and attest to the information contained within this form. That I release all claims, demands and/or liabilities arising out of Riggs Oil Co. Inc. dba Black Diamond Food & Gas verification of the facts contained within this application and/or interviews. The company retains the right to revise or amend its policies or procedures, in whole or in part, at any time.

I accept these terms & conditions