Bennett Auto Supply Employment Application

Personal Information

First Name Middle Initial Last Name	A value is required. A value is required.
Street Address
City, State, Zip	A value is required. A value is required. A value is required.
Home Phone Number	Work Phone Number
Cell Phone Number	E-mail Address A value is required.
Social Security Number	A value is required.
Have you used any name or social security numbers other than the above? If yes, please explain	Yes No
[For diving positions]
Driver's License State of Issue
Driver's License Number
Driver's License Expiration

Employment Desired

Position Applied For

A value is required.

How did you hear about this position?

Date available for work?

Desired Hours (full time, part time, etc.)

Education

High School (name,address,course of study,total years of study, and degree/diploma)

Undergraduate College(name,address,course of study,total years of study, and degree/diploma)

Graduate/Professional(name,address,course of study,total years of study, and degree/diploma)

Other(Specify)

List any seminars, classes or other education not listed above which may help qualify you for this position

Employment History

List below your past 3 employers, starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if you are attaching a resume.

May we contact your current employer?

Yes No

Employer (current yes no)	Start Date Format:(01/01/1999)	End Date Format:(01/01/1999)	Essential job functions of final position
Address			1.
City,ST,Zip	Starting Pay	Ending Pay	2.
Phone number			3.
Fax number	Supervisor(s)		4.
Job position(s)	E-amil address of supervisor
Reason(s) for leaving (or interested in leaving if currently employed)
What value did you add to this company or its customers?

Employer (current yes no)	Start Date Format:(01/01/1999)	End Date Format:(01/01/1999)	Essential job functions of final position
Address			1.
City,ST,Zip	Starting Pay	Ending Pay	2.
Phone number			3.
Fax number	Supervisor(s)		4.
Job position(s)	E-amil address of supervisor
Reason(s) for leaving (or interested in leaving if currently employed)
What value did you add to this company or its customers?

Employer (current yes no)	Start Date Format:(01/01/1999)	End Date Format:(01/01/1999)	Essential job functions of final position
Address			1.
City,ST,Zip	Starting Pay	Ending Pay	2.
Phone number			3.
Fax number	Supervisor(s)		4.
Job position(s)	E-amil address of supervisor
Reason(s) for leaving (or interested in leaving if currently employed)
What value did you add to this company or its customers?

List any professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability or any other protected status

List any languages other than English that you can speak, read or write that could be of benefit to the position applied for:

	Fluent	Good	Fair
Speak
Read
Write

Identify formal job training that relates to this position:
Identify what skills or certifications you have acwuired related to this position:
If hired, what value would you bring to this company?
Describe what you believe are the most unique features of your work history:

Additional Information

Have you ever been employed with this company before? Yes No

If Yes, when

Do you have any friends or revatives employed by this company? Yes No

If Yes, please provide their names and relationship to you

Are you currently employed? Yes No

May we contact your employer? Yes No

Are you currently on "lay off" status and subject to recall? Yes No

If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.? Yes No

Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation? Yes No

If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for? Yes No

if Yes, please explain

If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence"(DUI)"? Yes No N/A

If hired, do you have a reliable means of transportation to and from work? Yes No

If hired, would you be able to travel or work overtime or weekends as needed? Yes No

INSTRUCTIONS FOR ANSWERING APPLICATION QUESTION ABOUT BEING CONVICTED OF A CRIME OR OTHER STATE-SPECIFIC REQUIREMENTS

Please respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for which the criminal record has been expunged or sealed by the court or, misdemeanor convictions for which any probation has been completed and the case dismissed by the court. Furthmore, please note that no applicant will be denied employment soley on the grounds that they have been charged, committed or convicted of (or pleaded guilty or no contest in) a criminal offense, or soley on an affirmative answer. The nature, date, surrounding circumstances and relevance of the offense to the position(s) applied for will be considered. A criminal record does not constitute an automatic bar to employment and will be considered only as it substantially relates to the job in question. If you are applying for a position with our company in the following state, please read the instructions which follow below before responding.

Have you ever, under your name or another name, been convicted of (or pleaded no contest to) a felony or misdemeanor? Yes No

Have you ever, under your name or another name, been convicted of a crime, which resulted in your being in prison and/or jail and released from prison and/or jail or paroled? Yes No

If Yes to either question above, please fully explain when, where and of what you were convicted and the result of the case(s).

Are you currently under arrest, or released in bond on your own recognizance, pending trial for a criminal offense? Yes No

If yes, state the nature of the crime charged, and when and where the trial is pending

Have you used illegal drugs in the last six months? Yes No

Do you take illegal drugs or medications that have not been prescribed to you? Yes No

If Yes, to either of the above questions when was the last time you used illegal drugs?

Have you ever been convicted of driving under the influence(DUI)? Yes No

Do you use alcohol to the extent that it would impair your job performance? Yes No

Are you able to perform the essential function of the job you are applying for (with or without reasonable accommodation)? Yes No

If No, describe the functions that cannot be performed

References

List below three persons not related to you who have knowledge of your work performance within the last 5 years

Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Additional Information

Type Initials In Each Box

A value is required.Complete and Accurate Information

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

A value is required.At-Will Employment

I understand and agree that if I am employed, my employment will be "at-will". Which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, either expressed or implied to the contrary is hearby superceded and that no promise or represention contrary to the foregoing is binding on the Company unless made in writing and signed by the Company's president.

A value is required.Testing Authorization

If offered a position with the Company, I hereby agree to any leaglly permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

A value is required. Investigation Authorization

I authorize investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers and friends. Said investigation may include credit, driving, criminal background, references and other background checks. As a condition of applying for this job, I authorize reasonable post-hire investigations into my credit,driving and criminal background.

A value is required.Company Obligation

I understand and agree that the Company's acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.

PRE-EMPLOYMENT INFORMATION DISCLOSURE
NOTICE AND ACKNOWLEDGEMENT

JOB SITE: A value is required.
EMPLOYER: A value is required.
Full Name: A value is required.SS#: A value is required.
Any other name(s) used in the past or present: A value is required.
Address: A value is required.
City: A value is required. State: A value is required. Zip: A value is required.
Driver's License #: A value is required. State: A value is required.
(Only for motor vehicle report)
Date of Birth: A value is required.

In applying for employment with Bennett Auto Supply("Company"), I hereby authorize the
Company, or any designated agent(s) working on the Company's behalf, including but not
limited to reporting agencies or professional investors to obtain and review those reports checked
off below as well as following up in information presented in the reports. The Company, or its
agents may also request these reports and information during the course of any employment as a
condition of continued employment. My consent extends to any possible investigations
performed during the course of the employment, including those related to complaints of
discrimination, harassment, theft ot other conduct.

It is my understanding the information being obtained will not be used in violation of any federal
or state equal opportunity law or regulation, and that, before any adverse action is taken, based on
upon review of such consumer credit report, I will be provided with a copy of said report as well
as a summary of consumer's rights.

I understand the nature and scope of said inquiries may include, but are not limited to,
verification, inspection and/or reporting of any lawfully available records or information
pertaining to work history; social security number, education; workers' compensation claims,
criminal or civil court related actions; driving history (including traffic related offenses);
personal financial status(including consumer credit reports); and any other information available
from any public or otherwise documented record. It may also include inquires regarding any past
or present business, professional or personal activities.

I hereby state that to the best of my knowledge all information I have provided to the Company,
and any reporting agency, in any form, is true and accurate. I understand that any
misrepresentation made to the Company or reporting agency by me will exclude me from further
consideration as a candidate for employment or advancement, and may result in termination of
my employment with the Company if I am hired or advanced by the Company before such
misrepresentation is discovered. I fully understand this authorization, waiver and release of
liability is not an offer or a contract for employment by the Company. It is also understood that
the Company operates under an "at-will" employment policy and that this authorization and
release does not alter or affect this policy in any manner.

Authorization to Obtain Criminal Information A value is required. Initials

I hereby authorize the Company, reporting agency or investigator to request, obtain and
examine any and all records that may relate to my arrest, conviction and/or imprisonment
at any time prior to this date, to the extent permitted by law

Authorization to Obtain Credit Report A value is required. Initials

I hereby authorize the Company, reporting agency or investigator to make inquiry into,
investigate, and examine any and all records that may relate to my current or past credit
worthiness; such information to include (but not limited to) a retail credit report
provided by any of the commercial retail credit reporting companies.

Authorization to Obtain Background Report A value is required. Initials

I hereby autorize the Company, reporting agency or investigator to request and
employment background report.

Authorization to Obtain Educational Report A value is required. Initials

I hereby autorize the Company or reporting agency or investigator to request and educational background
report.

Authorization to Obtain Motor Vehicle Records A value is required. Initials

I hereby autorize the Company, reporting agency or investigator to aquire and examine
a copy of my current Motor Vehicle Record.

Authorization to Obtain Past Workers Compensation History and Medical Information A value is required. Initials

I hereby autorize the Company, reporting agency, investigator or physician to aquire
and examine, after a conditioned job offer, information about past workers compensation
claims and medical history.

Authorization to Conduct Post-Hire Investigation A value is required. Initials

I hereby autorize the Company, reporting agency or investigator to obtain reports or
conduct investigations as a condition of continued employment.

MY ANSWERS HAVE BEEN TRUE AND ACCURATE PURSUANT TO THE PENALTY OF PERJURY UNDER THE LAWS OF THIS STATE. I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.

Full Name A value is required. Date A value is required.