Employment Application

Personal Information
Present Address
Name:
 Phone:
Address:
City:
 State:
 Zip:
Previous Address
Address:
City:
 State:
 Zip:
Are you 18 years or older?
Have you ever been Convicted of a felony or misdemeanor?
If yes, please describe:
*You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.
Are you able to perform all of the duties of the job for which you are applying?
If no, please describe which duties you are unable to perform and what accommodations may be necessary:
Employment Desired:
Specific job applied for: Date you can start:
 /  / 		 Salary desired:
Are you currently employed? If so, may we inquire of your present employer?
Have you ever applied at Grismer before? Where? When?
How did you hear about an available job at Grismer?
If referred by an employee please list their name:
Education
Name & location of high school:
 Years Attended:
 Did you Graduate?
 Subjects Studied:
Name & location of vocational/technical schoool: Years Attended:
 Did you Graduate?
 Subjects Studied:
Name & location of tech/college:
 Years Attended
 Did you Graduate?
 Subjects Studied:
Correspondence, Business, Driving or Trade School:
Specialized Skills(ie.: PC Typing, Forklift, Alignment, Tech, Retread, Etc.):
U.S. Military or Naval Service Branch:
Employment Experience
Start with your present or most recent job and list backward in order. Include military service assignments and volunteer work.
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
Employer:
 Phone:
 Address:
Job Title:
 Hourly Rate/Salary:
 Work Performed:
Supervisor:
 Reason For Leaving:
 Dates Employed:
 /  /  to  /  / 
References
Give names of two (2) people not related to you who are able to verify your employment and personal history.
Name: Address: Phone:
Name: Address: Phone:

ONLY CORPORATE OFFICE APPLICANTS MAY OMIT THIS PAGE
Driver Experience and Qualification
Name:
 Address:
City:
 State:
 Zip:
Date of Birth:
 Date of Employment:
 /  / 
Drivers License
State: License Number: Type/Class: Expiration Date:
 /  / 
A.) Have you had and moving, traffic violations in the past three (3) Years?
If you have answered yes, please explain in detail:
B.) Has any license, permit, or privilege ever been suspended or revoked?
If you have answered yes, please explain in detail:
C.) Have you had any auto accidents in the past three (3) years?
Status:
ACCIDENT RECORD FOR THE PAST 3 YEARS
Last Accident:
Date:
 /  / 		 Nature of Accident:
 Injuries:
Next Previous:
Date:
 /  / 		 Nature of Accident:
 Injuries:
Next Previous:
Date:
 /  / 		 Nature of Accident:
 Injuries:
Driver: I hereby grant permission for Grismer to secure a Motor Vehicle Record on me. I also affirm that the statements made above are stated truthfully and without reservation.
Applicant's Signature: Date:  /  / 
Authorization to Release Employment Reference Information

Applicants Agreement

I understand Grismer Tire Co. Inc., Associates, d.b.a. Grismer, Columbus Tire, d.b.a. as Grismer, and any subsequent company doing business as Grismer, subsequently referred to as Grismer, requires certain information about me to evaluate my qualifications for employment and conduct its business if I become an employee. I understand that the company may investigate my driving record, credit history and criminal record and I give Grismer permission to do so. I also understand that an investigative consumer report may be made, whereby, information is obtained through personal interviews with those with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics, financial responsibility, and mode of living. I understand that I have a right to make a written request, within a reasonable matter of time, to receive additional detailed information about the nature and scope of this investigative consumer report. I hereby release Grismer Tire Company Inc., and any persons, company, or institution that provides the Company with information from any and all liability for any damages that may result from the investigation, use, or disclosure of such information. I understand false, incomplete or misleading statements on this application may be considered sufficient cause for dismissal, if, and when discovered. I also understand that information provided on this application may be used to make an employment decision.

If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could reflect adversely on the company. I understand this decision is to rest with the company.

In addition, if accepted for employment I hereby agree to abide by the rules and policies of my employer and accept the established pay period as provided in accordance with the Fair Labor Standards Act (as amended). I agree to conform to the Company's rules and regulations, and I agree that my employment and compensation may be terminated, with or without cause, and with or without notice, at either my, or the company's option. I also understand and agree that the terms and conditions of my employment may be changed with or without notice, at any time by the company. I understand that no company representative, other than the President/Owner, and then only in writing and signed by the President/Owner, has the authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing "This is a true application seeking work only."
Complete Signature of Applicant Date  /  / 
Pre-Employment Consent/Waiver Form

One of the requirements for considerations of employment with Grismer is the satisfactory passing of a pre-employment urine drug test. The company has a policy prohibiting the possession, distribution, use, consumption of, or being under the influence of alcohol, illegal, unauthorized drugs, and other harmful substances in order to provide a safe environment for employees and customers. Those applicants considered as final candidates for employment will be required to undergo a urine drug test and will be dropped from considerations for employment if the test is positive. Individuals who have disqualified due to positive test results will be eligible to fe-apply for work one year after having been eliminated from considerations and can satisfactorily pass a pre-employment drug test.
Complete Signature Date  /  / 
Authorization And Wavier

I authorize and request my former employers, references, (including the U.S. Government and the U.S. Military, educational institutions, registration and licensing boards, credit agencies or reporting services which have information about me, to give Grismer Tire Co., Inc. and subsidiaries any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and I release such former employers, references, (including the U.S. Government and the U.S. Military, educational institutions, registration and licensing boards, credit agencies or reporting services, from any liability or claim relating to such release of information and opinions. I also authorize and request, federal, state, and local governmental agencies to release to Grismer Tire Co., Inc. including all subsidiaries any information requested concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.
Signature Date  /  / 
Submit