Employment Application

Personal Information

Name:

Date:

Present Address:

Previous Address:

Email Address:

Contact Number:

Are you 18 years or older?:

Yes

Have you ever been convicted of a felony or misdemeanor?*:

Yes

If yes, 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?*:

Yes

If no, please describe which duties you are unable to perform and what accommodations may be necessary:

*Applicants will not necessarily be disqualified if they are unable to perform a particular job duty (or duties).

Employment Desired

Full Time

Part Time

Temporary

Desired Job:

Date you can start:

Salary desired:

Are you employed now?:

If so, may we inquire of your present employer?:

Yes

Ever applied to this company before? :

Yes

When and Where?:

Referred by:

Education

Please list the name and location of the prep/highschool you attended, how many years you were there, did you graduate, and what you studied.

Please list the name and location of the technical school you attended, how many years you were there, did you graduate, and what you studied.

Please list the name and location of the college or post secondary school you attended, how many years you were there, did you graduate, and what you studied.

Please list the name and location of the Correspondence, Business, Driving or Trade School you attended.

Please list if you were in the U. S. Military or Naval Service Branch.

Employment History

By printing: list all present and past employment beginning with the most recent, including any military service assignments and volunteer work.

Employer Name:

Employer Address:

Phone Number:

Date Started and Ended:

Job Title:

Work Performed:

Supervisor:

Reason For Leaving:

Hourly Rate/Salary Starting and Ending:

Employer Name:

Employer Address:

Phone Number:

Date Started and Ended:

Job Title:

Work Performed:

Supervisor:

Reason For Leaving:

Hourly Rate/Salary Starting and Ending:

Employer Name:

Employer Address:

Phone Number:

Date Started and Ended:

Job Title:

Work Performed:

Supervisor:

Reason For Leaving:

Hourly Rate/Salary Starting and Ending:

References

Provide names of two (2) persons not related to you who are able to verify your employment and personal history.

Reference Name:

Reference's Address:

Business:

Reference's Phone Number:

Reference Name:

Reference's Address:

Business:

Reference's Phone Number:

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/WAVIER 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 re 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 WAIVER

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:

CANDIDATE DRIVER EXPERIENCE AND QUALIFICATIONS

**If you are applying for a position where you will be responsible for driving a
company and/or customer vehicle, you must complete all information fields below.

Name:

Address:

City, State:

Zip Code:

Date of birth:

Date of Employment:

Have you had any moving, traffic violations in the past three (3) years?:

Yes

If you have answered yes, please explain in detail :

Has any license, permit, or privilege ever been suspended or revoked?:

Yes

If you have answered yes, please explain in detail :

Have you had any auto accidents in the past three (3) years?:

Yes

Status: Employee: :

Non Employee: An applicant for employment:

ACCIDENT RECORD FOR THE PAST 3 YEARS (attach sheet if more space is needed)

List your recent car accident such as the date, the nature of the accident, and if there were any injuries.

Driver: I hereby grant permission for Grismer, to secure my Motor Vehicle Record. I also affirm that the statements made above are stated truthfully and without reservation.

List your recent car accident such as the date, the nature of the accident, and if there were any injuries.

Permission Statement:

Signed Date: