An Equal Opportunity Employer
We consider applicants for all positions without regard to race, color, religion, sex, national origin, marital or veteran status, the presence of any physical or mental condition or disability, or any other legally protected status.

PLEASE READ CAREFULLY, ANSWER COMPLETELY AND ACCURATELY.  Only completed applications will be evaluated, do not indicate "see resume".  If you require accommodation due to a disability in order to complete the application, please let us know what accommodation you require.  LCC refers to Loma Catalina Company, LLC. 

Applicant Information

Last:	First:	Middle:
Social Security No.:	Who referred you to our company?
Have you ever worked under a different name?  If yes, what name(s)?
Current Address:
	City:    State    Zip
Home Phone:
Other Phone:	=choose= Cell Work
Work Hours:
Do you have the legal right to work in the US?   =choose= Yes No
If no, please explain:
No records returned.

Availability

I am available to work the following:  =choose= Full-time Part-time Days Evenings Overnight Any Shift
I am available to work the following hours:
If your application is considered favorably, on what date will you be available for employment?
=month= January February March April May June July August September October November December =date= 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Have you ever applied for employment with us?  If so, when?  Where?
=choose= Yes No
Were you previously employed by LCC or Chevron Stations, Inc. or Roadrunner Depot? If so, please provide the starting and ending dates of your employment:
=choose= Yes No  employed from   to
Position	Reason for leaving:
Are you related to any LCC Employee? =choose= Yes No

Criminal Background

Have you ever been convicted of a crime?		=choose= Yes No
If so, please provide details, dates, places, charges and final disposition:
- Do not include moving or parking violations or infractions.  - Do include anything more serious - A conviction will not necessarily disqualify you from employment.
Are you now awaiting trial or sentencing for any crime?		=choose= Yes No
If so, please provide details:

Employment:
list all of your previous employers for the past seven years.  Start with your current or most recent employer.

Employer #1:    Phone:    Employer's address:     Dates of employment: to   Salary per   Position:   Supervisor's Name:   Reason for leaving:   Employer #2:    Phone:    Employer's address:     Dates of employment: to   Salary per   Position:   Supervisor's Name:   Reason for leaving:   Employer #3:    Phone:    Employer's address:     Dates of employment: to   Salary per   Position:   Supervisor's Name:   Reason for leaving:   Employer #4:    Phone:    Employer's address:     Dates of employment: to   Salary per   Position:   Supervisor's Name:   Reason for leaving: Please explain any gaps in employment:

Education

High School name: Location: Highest Grade Completed: =choose= N-A 9 10 11 12 Degree Earned: Major Studies:     College name: Location: Highest Grade Completed: =choose= N-A 1 2 3 4 5+ Degree Earned: Major Studies:     Graduate School  name: Location: Highest Grade Completed: =choose= N-A 1 2 3 4 5+ Degree Earned: Major Studies:

Background Investigation data
We will conduct a background check on applicants selected for employment.  As part of your background check, you must provide the information requested below for the last SEVEN YEARS for both your residence and your past employment.  If you need additional space, please use a blank sheet of paper.

Current Address: City    State    Zip       How long have you lived at this address?   Previous Address: City    State    Zip       How long have you lived at this address?   Previous Address: City    State    Zip       How long have you lived at this address?

Personal References
List 3 personal references.  Do not include relatives, in-laws, or people who share your current address.  Give complete and accurate information.

Name: Address: City State Zip Phone: How many years has this person known you?     Name: Address: City State Zip Phone: How many years has this person known you?     Name: Address: City State Zip Phone: How many years has this person known you?

Please read carefully and sign below:
I hereby declare that the information provided by me in this application for employment is true, correct and complete to the best of my knowledge.  I understand that if employed, any misstatement, false statements or omission of fact on this application shall result in rejection of this application or termination of employment.  I understand that this application is valid for thirty days.  I must reapply to be considered after this period.  I understand that all job offers made by an authorized representative of Loma Catalina Company are contingent upon passing a drug screen, presenting documents to conform with the Immigration Reform and Control Act and form I-9, and background investigation.  In consideration of my employment, I agree to conform to the rules and regulations of Loma Catalina Company and that my employment and compensation can be terminated with or without cause, and with or without notice at any time, at the option of the company or myself.  I understand that only the President of the Company has the authority to enter into any employment agreement for specified period of time and that such agreement must be in writing.

All applications being considered for employment must submit to and pay for a drug screen at J2 Laboratories, 3640 N 1st Avenue, Tucson AZ, on the day specified by your interviewer.  You must initially pay $27.00 for the drug screen.  LCC will reimburse all applicants from whom we request a drug screen if the report we receive is negative for all illegal and undisclosed controlled substances for which we test, whether or not you are ultimately hired.  LCC will not reimburse for drug screens that are positive for illegal substances.

By typing your name on this form, you agree to the terms and conditions set forth in this form.  If you do not agree to them, do not submit this form.