PAGE 1 OF 6

HEARTLAND AUTOMOTIVE SERVICES, INC.

THE LARGEST JIFFY LUBE FRANCHISEE GROUP IN AMERICA!
Corporate Office
11308 Davenport Street, Omaha, NE 68154 Phone: (402) 333-0990

EMPLOYMENT APPLICATION

PLEASE REVIEW THE FOLLOWING EMPLOYMENT REQUIREMENTS:

● You MUST fill out the application completely.
Incomplete applications will not be considered.
● You MUST be at least 16 years of age for some positions, and 18 years of
age for other positions.
Check with the Manager for details.
● You MUST possess a valid driver's license.
There are no exceptions.
● You MUST be able to read, write, and speak English.
This is due to safety concerns and customer service requirements.

TESTS AND CHECKS WILL BE CONDUCTED:

(Not limited to, but including some or all of the following)
● Criminal Background ● Substance Abuse
● Social Security Number Verification ● Worker's Compensation Claim History
● Sexual Offender Database ● Employment References
● Driving Record ● Credit Check (Select Positions)

If the box below contains an address, please forward the completed application to that address.

If no address is provided - please indicate the city and state you are interested in working
 in the box above, and mail your application to the company's corporate office address above.
You may also submit your completed application at any area Jiffy Lube.

APPLICANT INFORMATION PAGE 2 OF 6

Heartland Automotive Services, Inc. dba Jiffy Lube is an Equal Opportunity Employer and considers employment applicants without
regard to sex, age, race, religion, color, national origin, citizenship, disability, veteran status, or any other status protected by law.
Answer all questions completely, truthfully, and accurately, but do not provide information that has not been requested, as it may result
in your application being rejected.
POSITION APPLYING FOR

NAME (First, Middle Initial, Last) PRIMARY PHONE SECONDARY PHONE

ADDRESS APT / UNIT # EMAIL ADDRESS

CITY STATE ZIP

YES / NO IF NO, ARE YOU YES / NO DATE AVAILABLE TEMP / FT / PT / ANY

ARE YOU AN UNITED
AUTHORIZED TO WORK
STATES CITIZEN?
IN THE US?

YES / NO IF YES, WHEN? YES / NO IF YES, START DATE

HAVE YOU EVER HAVE YOU EVER WORKED
APPLIED HERE BEFORE? HERE BEFORE?

END DATE WHY DID YOU LEAVE?

YES / NO IF YES, NUMBER STATE EXPIRATION DATE

DO YOU HAVE A VALID
DRIVER'S LICENSE?

IMPORTANT - PLEASE READ QUESTION CAREFULLY AND IF YOU ANSWER YES, GIVE DETAILS BELOW. YES / NO

HAVE YOU PLED GUILTY OR "NO CONTEST" TO, OR BEEN CONVICTED OF A MISDEMEANOR OR FELONY IN THE PAST 7
YEARS?
A "YES" response does not constitute an automatic bar to employment. Factors such as age, time since the offense, seriousness and nature of the
violation, job-relatedness, and rehabilitation will be taken into account. Do not include minor traffic infractions or convictions for which the record has
been sealed or expunged.

**CA Applicants ONLY**- Do not include any marijuana-related offenses that occurred over two (2) years ago in answer to this question or any
misdemeanor conviction for which probation has been successfully completed or otherwise discharged.

**MA Applicants ONLY**- Do not include any information which is more than 5 years old. An applicant for employment with a sealed record on file with
the commissioner of probation may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions.
In addition, any applicant for employment may answer ‘no record’ with respect to any inquiry relative to prior arrests, court appearances and
adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal
prosecution.

▼ IF YOU ANSWERED "YES" TO THE QUESTION ABOVE, INCLUDE DETAILS HERE ▼

 MILITARY INFORMATION PAGE 3 OF 6

YES / NO IF YES, BRANCH ENTER DATE DISCHARGE DATE

HAVE YOU EVER
SERVICE IN THE
MILITARY?

DESCRIBE DUTIES YES / NO HIGHEST RANK

ARE YOU CURRENTLY IN
THE RESERVES?

EDUCATION / CERTIFICATIONS
HIGH SCHOOL CITY / STATE FROM TO

YES / NO DESCRIBE COURSE OF STUDY RELATIVE TO THE POSITION YOU ARE APPLYING
DID YOU GRADUATE?

COLLEGE CITY / STATE FROM TO

YES / NO DEGREE / SPECIAL COURSE OF STUDY INFORMATION

DID YOU GRADUATE?

OTHER CITY / STATE FROM TO

YES / NO DEGREE / SPECIAL COURSE OF STUDY INFORMATION

DID YOU GRADUATE?

SPECIAL TRAINING / SKILLS / EXPERIENCE

PROFESSIONAL REFERENCES
NAME COMPANY NAME POSITION TELEPHONE NUMBER

NAME COMPANY NAME POSITION TELEPHONE NUMBER

NAME COMPANY NAME POSITION TELEPHONE NUMBER

IF YOU HAVE ANY FRIENDS / FAMILY WORKING FOR HEARTLAND AUTOMOTIVE SERVICES, PROVIDE THE INFORMATION INDICATED

NAME LOCATION POSITION RELATION

NAME LOCATION POSITION RELATION

NAME LOCATION POSITION RELATION

PREVIOUS EMPLOYMENT PAGE 4 OF 6

Please list the names of your present or previous employers (of at least the past 10 years) in chronological order with present or last employer listed first. Be sure to account
for all periods of time including military service, verifiable volunteer work, and any period of unemployment. If self-employed, give firm name and supply business references.
(Add additional pages if necessary).

Start with Most Recent

COMPANY NAME CITY / STATE FROM TO

JOB TITLE / POSITION DESCRIPTION STARTING WAGE ENDING WAGE

RESPONSIBILITIES REASONS FOR LEAVING

SUPERVISOR'S NAME POSITION PHONE NUMBER

COMPANY NAME CITY / STATE FROM TO

JOB TITLE / POSITION DESCRIPTION STARTING WAGE ENDING WAGE

RESPONSIBILITIES REASONS FOR LEAVING

SUPERVISOR'S NAME POSITION PHONE NUMBER

COMPANY NAME CITY / STATE FROM TO

JOB TITLE / POSITION DESCRIPTION STARTING WAGE ENDING WAGE

RESPONSIBILITIES REASONS FOR LEAVING

SUPERVISOR'S NAME POSITION PHONE NUMBER

COMPANY NAME CITY / STATE FROM TO

JOB TITLE / POSITION DESCRIPTION STARTING WAGE ENDING WAGE

RESPONSIBILITIES REASONS FOR LEAVING

SUPERVISOR'S NAME POSITION PHONE NUMBER

ALL APPLICANTS MUST READ AND SIGN PAGE 5 OF 6

Supplying the requested information to Heartland Automotive Services, Inc. (Heartland) establishes me as a candidate for employment with
Heartland. It does not constitute an offer or promise of employment. I understand that a candidate is someone who may express interest in but is not
considered for a specific position. An applicant is someone who expresses interest in and is considered for a specific position, and who otherwise
meets the minimum qualifications for that position. I understand that I must be able to perform the essential functions, with or without
accommodation, of any job for which I apply.

I understand and agree that if I am employed by Heartland my employment will be for an indefinite period. There are no guarantees, expressed or
implied, as to how long I will be employed with Heartland. I understand that an employment relationship between Heartland. and all of its employees
is based upon mutual consent and may be terminated at any time by the employee or Heartland without advance notice or cause, that is, at will. I
further understand that no employee or representative of Heartland has any authority to alter the terms of my employment through oral statements or
promises, and that to be binding on Heartland, any agreement or promise that alters my at-will status must be in writing and approved by the
President or CEO of Heartland.

As allowed by law, I hereby grant permission to Heartland to conduct pre-employment and subsequent drug and alcohol tests, to investigate my
previous employment, educational background, character references, credit history, driving record, criminal history and any other information
included in the application, my resume, any other attachments to the application, or otherwise disclosed or obtained during the employment process,
at any time prior to my employment or following my employment. I understand that Heartland relies upon such statements in making its employment
decisions, and I authorize Heartland to investigate all such statements contained herein. If requested, I agree to be fingerprinted prior to or during my
employment with Heartland.

If employed in a state that requires using E-Verify, my information will be submitted to the government to confirm my work authorization. I will be
required to present the required documentation with photo ID in connection with completing the I-9 form. In addition, future verification of my work
authorization may be required by law. If the government’s system does not immediately verify my work authorization, I will be provided with
instructions and an opportunity to contact the government and resolve any issues. If my work authorization cannot be verified through the E-Verify
system, Heartland cannot continue to employ me and my employment will be terminated.

I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal
knowledge about me, to furnish any and all information in their possession regarding me in connection with my application for employment with
Heartland. I also expressly waive any claim for damages or liability against any person or entity for providing any information sought by Heartland
pertaining to its review of my suitability for employment, including any information regarding my performance with and reason for separation from
any previous employment.

I acknowledge that I have been advised and have hereby received notice in connection with the Fair Credit Reporting Act that, in connection with my
application for employment, an investigative consumer inquiry and report may be made that will provide applicable information concerning my
character, reputation, and mode of living. I hereby grant permission to Heartland to conduct or cause to be conducted such an inquiry. Upon written
request, disclosure of the nature and scope of the investigation will be provided to me. I waive any liability against Heartland its agents or
employees from any claims, including negligence or gross negligence relating to any investigation, examination or inquiry concerning my
background to determine my suitability for initial or continued employment.

I certify that all of the information provided for consideration of employment with Heartland including my application and any attachments, resume,
and interview, is true, complete and correct. I understand that if I failed to provide complete and truthful answers to the questions asked during the
application process or if any of my responses are incomplete, false or misleading that I will not be given further consideration for employment, or
Heartland will consider me ineligible for employment, and, if employed, no longer eligible for continued employment regardless of when the
misinformation is discovered.

In the event that I am employed by Heartland, I will comply with all existing and future rules, policies, and regulations of Heartland. If employed, I
understand and agree that I must not and will not at any time communicate or reveal to anyone except authorized personnel of Heartland in the course
of business, any confidential or proprietary information concerning Heartland business or concerning any person or organization with whom
Heartland has a business relationship. I fully understand that any violation of the confidentiality policy will be grounds for immediate dismissal from
Heartland employment.

I understand that, as a condition of employment, Heartland has a mandatory arbitration policy for all disputes. I understand and agree that submitting
this application or accepting employment will constitute my agreement to arbitrate any disputes that arise from or relate in any way to consideration
for employment with Heartland.
I understand that, as a condition of employment, Heartland has a mandatory arbitration policy for all disputes. I understand and agree that submitting
this application or accepting employment will constitute my agreement to arbitrate any disputes that arise from or relate in any way to consideration
for employment with Heartland.
I certify that I’ve read, fully understand, and accept all terms listed above. I also understand that if I do not agree with this certification, I will not be
considered for employment with Heartland.
Sign or type your full legal name in the "Electronic Signature" box below. A typed signature will be considered the same as your signed
signature and it will imply your agreement and understanding of the statements above.
PRINT NAME
DISCLOSURE AND AUTHORIZATION
IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Heartland Automotive Services, Inc. (“the Company” or “Employer”) may obtain
information about you from a consumer reporting agency for employment purposes.
Thus, you may be the subject of a “consumer report” and/or an “investigative
consumer report” which may include information about your character, general
reputation, personal characteristics, and/or mode of living, and which can involve
personal interviews with employers and/or associates. Please be advised that the
nature and scope of the most common form of investigative consumer report obtained
with regard to applicants for employment is an investigation into your education and/or
employment history. These reports may be obtained at any time after receipt of your
authorization and, if you are hired, throughout your employment. You have the right,
upon written request made within a reasonable time after receipt of this notice, to
request disclosure of the nature and scope of any investigative consumer report.
The scope of this notice and authorization is all-encompassing, however, allowing
Employer to obtain from it’s background investigation provider all manner of consumer
reports and investigative consumer reports now and, if you are hired, throughout the
course of your employment to the extent permitted by law. As a result, you should
carefully consider whether to exercise your right to request disclosure of the nature
and scope of any investigative consumer report.
New York applicants or employees only: You have the right to inspect and receive a
copy of any investigative consumer report requested by Employer. The employer will
provide you with the address upon request. By signing below, you also acknowledge
receipt of Article 23-A of the New York Corrections Law.
Sign or type your full legal name in the "Electronic Signature" box below. A typed
signature will be considered the same as your signed signature and it will imply your
agreement and understanding of the statements above.
PRINT NAME
Last Name
First Name
Other Name
Address
City
Date of Birth Social Security No.
Driv Lic No.
Home Phone ▬ ▬ Cell Phone
STATE COUNTY ZIP FROM TO
Other States &
Counties I 1 1
have lived
2 2
FROM HERE DOWN - CALIFORNIA APPLICANTS ONLY
Employer (the “Company”) intends to obtain information about you from an investigative
consumer reporting agency and/or a consumer credit reporting agency for employment
purposes. Thus, you can expect to be the subject of “investigative consumer reports” and
“consumer credit reports” obtained for employment purposes. Such reports may include
information about your character, general reputation, personal characteristics and mode of
living. With respect to any investigative consumer report from an investigative consumer
reporting agency (“ICRA”), the Company may investigate the information contained in your
employment application and other background information about you, including but not
limited to obtaining a criminal record report, verifying references, work history, your social
security number, your educational achievements, licensure, and certifications, your driving
record, and other information about you, and interviewing people who are knowledgeable
about you. The results of this report may be used as a factor in making employment
decisions.
SIGNATURE DATE
PAGE 6 OF 6
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE REGARDING BACKGROUND
INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR
CREDIT REPORTING ACT and certify that I have read and understand both of
those documents. I hereby authorize the obtaining of “consumer reports” and/or
“investigative consumer reports” at any time after receipt of this authorization and, if
I am hired, throughout my employment. To this end, I hereby authorize, without
reservation, any law enforcement agency, administrator, local, state or federal
agency, institution, school or university (public or private), information service
bureau, employer, or insurance company to furnish any and all background
information (including, but not limited to, driving and/or motor vehicle records,
transcripts, grades and attendance records, employment history, salary information
and references, workers compensation reports in Pennsylvania, Arizona and in all
other states, drug and alcohol testing results) requested by any background
investigation provider acting on behalf of Employer, and/or Employer itself.
I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as
valid as the original.
Minnesota and Oklahoma applicants or employees only: Please check this box if
you would like to receive a copy of a consumer report if one is obtained by the
Company. [ ]
California applicants or employees only: By signing below you also acknowledge
receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO
CALIFORNIA LAW. Please check this box if you would like to receive a copy of an
investigative consumer report or consumer credit report if one is obtained by the
Company at no charge whenever you have a right to receive such a copy under
California law. [ ]
SIGNATURE DATE
Middle Name
Apt.
State Zip
State Email:
▬ ▬
STATE COUNTY ZIP FROM TO
• In person, by visual inspection of your file during normal business hours and on reasonable
notice. You also may request a copy of the information in person. The ICRA may not charge you
more than the actual copying costs for providing you with a copy of your file.
• A summary of all information contained in the ICRA’s file on you that is required to be
provided by the California Civil Code will be provided to you via telephone, if you have made a
written request, with proper identification, for telephone disclosure, and the toll charge, if any,
for the telephone call is prepaid by or charged directly to you.
• By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with
requests for certified mailings shall not be liable for disclosures to third parties caused by
mishandling of mail after such mailings leave the ICRAs.
living. With respect to any investigative consumer report from an investigative consumer
reporting agency (“ICRA”), the Company may investigate the information contained in your
employment application and other background information about you, including but not
limited to obtaining a criminal record report, verifying references, work history, your social
security number, your educational achievements, licensure, and certifications, your driving
record, and other information about you, and interviewing people who are knowledgeable
about you. The results of this report may be used as a factor in making employment
decisions.
The source of any investigative consumer report (as that term is defined under California
law) will be made available to you upon request.
The Company agrees to provide you with a copy of an investigative consumer report when
required to do so under California law.
Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is
in the ICRA’s file on you with proper identification, as follows:
PRINT NAME - CALIFORNIA APPLICANTS ONLY SIGNATURE - CALIFORNIA APPLICANTS ONLY
Internal Use Only: Fax this completed page along with the Background Request Form to (773) 303-8775
written request, with proper identification, for telephone disclosure, and the toll charge, if any,
for the telephone call is prepaid by or charged directly to you.
• By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with
requests for certified mailings shall not be liable for disclosures to third parties caused by
mishandling of mail after such mailings leave the ICRAs.
“Proper Identification” includes documents such as a valid driver’s license, social security account
number, military identification card, and credit cards. Only if you cannot identify yourself with such
information may the ICRA require additional information concerning your employment and personal
or family history in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will
provide a written explanation of any coded information contained in files maintained on you. This
written explanation will be provided whenever a file is provided to you for visual inspection.
You may be accompanied by one other person of your choosing, who must furnish reasonable
identification. An ICRA may require you to furnish a written statement granting permission to the
ICRA to discuss your file in such person’s presence.
DATE