APP L I C AT I ON F OR E M PLOYMENT
Skills & Experience
Please list any special qualifications, training, education, skills or experience that you feel warrant consideration by the
company. _____________________________________________________________________________________________
Personal Information
Name____________________________________________________ Social Security No.____________________________
Street Address__________________________________________________________ Apt. No.________________________
City__________________________________________________ State_______________________ Zip__________________
Phone No.__________________________________________ Cell No.___________________________________________
Are you related to or acquainted with anyone now employed by Break Time Convenience Stores or any of its associated
companies? o Yes o No
If yes, indicate name, relationship and company where employed._______________________________________________
______________________________________________________________________________________________________
Have you ever applied at Break Time Convenience Stores or any of its associated companies? o Yes o No
If so, when?_____________________________________________________________________________________
If so, dates:
From________________ to __________________
Position______________________________
Who referred you to Break Time Convenience Stores?_________________________________________________________
Is this person a current employee? o Yes o No
Can present employer be contacted? o Yes o No
Please list any business equipment operating abilities you have which might be useful on the job for which you are
applying. _____________________________________________________________________________________________
Do you have reliable transportation? o Yes o No
Employment History
1
Present or Last Employer
Ending Date
Salary expected:_____________________________________ Location preference:__________________________________
Starting Date
What times are you available to work?______________________________________________________________________
Overnights? o Yes o No
o Yes o No
Holidays?
Weekends?
Final Salary
Overtime? o Yes o No
o Yes o No
Job Title
Ending Date
Address
Starting Salary
Final Salary
Job Title
If a resident of Arkansas, are you a least 21 years old? o Yes o No
Present or Last Employer
Have you ever been convicted of, pled guilty, nolo contendre or no contest to, or otherwise been found guilty of any crime
(including a suspended imposition of sentence)? o Yes o No
Conviction will not necessarily disqualify applicant from employment.
Starting Date
Ending Date
Final Salary
Job Title
If yes, please explain:_____________________________________________________________________________________
Education
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
1
2
3
Grade, Trade or High School
4
5
6
7
High School Name
8
9
10
11
12
Technical, Business School, College
1
2
3
4
Graduate School
5
Location
1
Did you graduate?
2
3
Location
Dates Attended Did you
Date of
(From-To)
graduate? graduation
College
Major
Grade Point Average
Degree
Received
• Health Insurance
• Review After 90 Days
• Dental Insurance
• Bonuses
• Paid Vacation Days
• Paid Vacation Days
• Paid Sick Leave
State
(hourly employees)
• Flexible Schedules
• Advancement Opportunities
Employer’s Phone No.
City
• Awards for Years of Service
State
• Long-Term Disability Insurance
• Prescription Drug Card
• Flexible Spending Accounts
• Retirement Benefits
• 401k Plan
• Direct Payroll Deposit
• Limited Medical Insurance
• Holiday Pay
Employer’s Phone No.
• Life Insurance
• Discounted Fountain Drinks or
Coffee (while on duty)
It is Break Time’s mission to deliver
fast and friendly service in a clean,
well-merchandised store.
Have you ever been involuntarily terminated or asked to resign from any position of employment? o Yes o No
4
o Yes o No
List every Business or Trade
School or College attended
City
Supervisor’s Name
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
Circle last year completed:
• Competitive Wages
• Friendly Work Environment
Address
Starting Salary
Store Manager positions offer:
• Weekly Pay
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
3
Are you a U.S. citizen or otherwise authorized to work in the U.S.? o Yes o No
All positions offer:
(full-time employees)
Employer’s Phone No.
Supervisor’s Name
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
If a resident of Missouri, are you at least 18 years old? o Yes o No
State
Supervisor’s Name
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
Present or Last Employer
o Yes o No
Starting Salary
City
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
For what position are you applying?________________________ o Full-time o Part-time
Are you willing to work: Evenings?
Address
2
How many hours per week do you want to work?________________ When could you begin?__________________________
JOIN A WINNING TEAM
______________________________________________________________________________________________________
Starting Date
Have you ever worked at Break Time Convenience Stores or any of its associated companies? o Yes o No
______________________________________________________________________________________________________
Grade Point
Average
References
Name & Address
If you did not graduate from college, how many total college hours do you have? ___________________________________
04/10
We are looking for team members
to help us achieve our goal.
If yes, please describe the circumstances:____________________________________________________________________
Years
Acquainted
Phone Number
MFA Petroleum Company
One Ray Young Drive
Columbia, Missouri 65201
(573) 442-0171 / (800) 366-0200
www.mfaoil.com
Break Time Convenience Stores is an Equal Opportunity Employer and promotes
a drug-free workplace. A pre-employment drug screen and criminal background
check are required for all new hires.
All potential employees are evaluated without regard to race, color, religion, gender,
national origin, age, marital or veteran status, the presence of non-job related
handicap or any other legally protected status.
APP L I C AT I ON F OR E M PLOYMENT
Skills & Experience
Please list any special qualifications, training, education, skills or experience that you feel warrant consideration by the
company. _____________________________________________________________________________________________
Personal Information
Name____________________________________________________ Social Security No.____________________________
Street Address__________________________________________________________ Apt. No.________________________
City__________________________________________________ State_______________________ Zip__________________
Phone No.__________________________________________ Cell No.___________________________________________
Are you related to or acquainted with anyone now employed by Break Time Convenience Stores or any of its associated
companies? o Yes o No
If yes, indicate name, relationship and company where employed._______________________________________________
______________________________________________________________________________________________________
Have you ever applied at Break Time Convenience Stores or any of its associated companies? o Yes o No
If so, when?_____________________________________________________________________________________
If so, dates:
From________________ to __________________
Position______________________________
Who referred you to Break Time Convenience Stores?_________________________________________________________
Is this person a current employee? o Yes o No
Can present employer be contacted? o Yes o No
Please list any business equipment operating abilities you have which might be useful on the job for which you are
applying. _____________________________________________________________________________________________
Do you have reliable transportation? o Yes o No
Employment History
1
Present or Last Employer
Ending Date
Salary expected:_____________________________________ Location preference:__________________________________
Starting Date
What times are you available to work?______________________________________________________________________
Overnights? o Yes o No
o Yes o No
Holidays?
Weekends?
Final Salary
Overtime? o Yes o No
o Yes o No
Job Title
Ending Date
Address
Starting Salary
Final Salary
Job Title
If a resident of Arkansas, are you a least 21 years old? o Yes o No
Present or Last Employer
Have you ever been convicted of, pled guilty, nolo contendre or no contest to, or otherwise been found guilty of any crime
(including a suspended imposition of sentence)? o Yes o No
Conviction will not necessarily disqualify applicant from employment.
Starting Date
Ending Date
Final Salary
Job Title
If yes, please explain:_____________________________________________________________________________________
Education
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
1
2
3
Grade, Trade or High School
4
5
6
7
High School Name
8
9
10
11
12
Technical, Business School, College
1
2
3
4
Graduate School
5
Location
1
Did you graduate?
2
3
Location
Dates Attended Did you
Date of
(From-To)
graduate? graduation
College
Major
Grade Point Average
Degree
Received
• Health Insurance
• Review After 90 Days
• Dental Insurance
• Bonuses
• Paid Vacation Days
• Paid Vacation Days
• Paid Sick Leave
State
(hourly employees)
• Flexible Schedules
• Advancement Opportunities
Employer’s Phone No.
City
• Awards for Years of Service
State
• Long-Term Disability Insurance
• Prescription Drug Card
• Flexible Spending Accounts
• Retirement Benefits
• 401k Plan
• Direct Payroll Deposit
• Limited Medical Insurance
• Holiday Pay
Employer’s Phone No.
• Life Insurance
• Discounted Fountain Drinks or
Coffee (while on duty)
It is Break Time’s mission to deliver
fast and friendly service in a clean,
well-merchandised store.
Have you ever been involuntarily terminated or asked to resign from any position of employment? o Yes o No
4
o Yes o No
List every Business or Trade
School or College attended
City
Supervisor’s Name
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
Circle last year completed:
• Competitive Wages
• Friendly Work Environment
Address
Starting Salary
Store Manager positions offer:
• Weekly Pay
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
3
Are you a U.S. citizen or otherwise authorized to work in the U.S.? o Yes o No
All positions offer:
(full-time employees)
Employer’s Phone No.
Supervisor’s Name
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
If a resident of Missouri, are you at least 18 years old? o Yes o No
State
Supervisor’s Name
If we contact this employer, would you expect them to say they would rehire you? o Yes o No
Explain.
Present or Last Employer
o Yes o No
Starting Salary
City
Job Type: o Full-time Job Description & Responsibilities
o Part-time
Explain reason/circumstances for changing or wanting to change jobs.
For what position are you applying?________________________ o Full-time o Part-time
Are you willing to work: Evenings?
Address
2
How many hours per week do you want to work?________________ When could you begin?__________________________
JOIN A WINNING TEAM
______________________________________________________________________________________________________
Starting Date
Have you ever worked at Break Time Convenience Stores or any of its associated companies? o Yes o No
______________________________________________________________________________________________________
Grade Point
Average
References
Name & Address
If you did not graduate from college, how many total college hours do you have? ___________________________________
04/10
We are looking for team members
to help us achieve our goal.
If yes, please describe the circumstances:____________________________________________________________________
Years
Acquainted
Phone Number
MFA Petroleum Company
One Ray Young Drive
Columbia, Missouri 65201
(573) 442-0171 / (800) 366-0200
www.mfaoil.com
Break Time Convenience Stores is an Equal Opportunity Employer and promotes
a drug-free workplace. A pre-employment drug screen and criminal background
check are required for all new hires.
All potential employees are evaluated without regard to race, color, religion, gender,
national origin, age, marital or veteran status, the presence of non-job related
handicap or any other legally protected status.
BECOME A BREAK TIME TEAM MEMBER
Signature
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigations of all
statements contained in this application for employment as may be necessary in arriving at an employment decision.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may
result in discharge at any time. I understand also that I am required to abide by all rules and regulations of Break Time
Convenience Stores.
I understand Break Time Convenience Stores will, as part of their normal employment procedure, require a criminal
background check and drug screen. I also understand that Break Time Convenience Stores may request a motor vehicle
report. By signing this application, I authorize MFA Petroleum Company to conduct the criminal background check, drug
screen and, if necessary, obtain my driving record.
I understand that, if hired by Break Time Convenience Stores, my employment is at will and may be severed by either
party at any time with or without cause. I understand that neither this document nor an offer of employment from Break
Time Convenience Stores constitute an employment contract unless a specific document to that effect is executed by the
employer and the employee in writing.
I understand that this application for employment will be considered active for a period of time not to exceed 45 days.
Signature of Applicant____________________________________________________ Date___________________________
Break Time is committed to its employees, customers and the communities in which we
operate. To that end, management and employees of Break Time have promised to uphold
the company’s code of ethics:
•
•
•
•
Maintain high standards of product quality and customer service;
Practice integrity, honesty and fairness with everyone at all times;
Make employees’ well-being a priority; and
Be a responsible citizen in the communities where we do business.
As a Break Time employee, your number one priority will be to provide excellent customer
service to each and every customer. Customers have many choices when deciding where to
do business. Our employees are the primary reason customers choose Break Time.
Greeting each customer with a smile and friendly welcome, making them aware of available
promotions and discounts and thanking them for their business at the end of the transaction
are all basic expectations for Break Time sales associates. Other basic expectations for
Break Time team members include wearing the proper uniform and following the company’s
personal appearance and uniform policy at all times; following carding polices on agerestricted alcohol and tobacco products; reporting to work as scheduled; and working in a
safe manner.
Break Time is operated by MFA Petroleum Company, headquartered in Columbia, Missouri.
FOR OFFICE USE ONLY
Hiring manager, be sure to record the following information obtained from the reference call.
1
Company Contacted
Person Contacted
Date of Contact
Dates of Employment
From:
To:
Position Held
Wage/Salary
Would you rehire?
o Yes o No
Reason for leaving:___________________________________________
Reference check performed by_________________________________________ Title____________________________
2
Company Contacted
Person Contacted
Date of Contact
Dates of Employment
From:
To:
Position Held
Wage/Salary
Would you rehire?
o Yes o No
Reason for leaving:___________________________________________
Reference check performed by_________________________________________ Title____________________________
3
Company Contacted
Person Contacted
Date of Contact
Dates of Employment
From:
To:
Position Held
Wage/Salary
Would you rehire?
o Yes o No
Reason for leaving:___________________________________________
Reference check performed by_________________________________________ Title____________________________
Learn more about Break Time Convenience Stores at www.mfaoil.com
04/10
APPLIC ATION FOR EMPLOYMENT