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Southern Tire Mart Employment Form

General Information

Today's Date

First Name	Last Name

Middle Initial	Social Security Number

Home Phone	Work Phone

Applicant Note

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an officer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

Address

Current Address

City	State	Zip

Prior Address

City	State	Zip

Availability

Job-Related Skills

Note: Do not fill out any portion of this section you believe to be non-job related.

Yes	No	If the job requires, do you have the appropriate valid driver's license?
		Name on License	DL#	Type	State of Issue

Yes	No	Have you had any moving violations within the last 7 years?
		Please Describe.
Yes	No	Have you been given a job description or had the essential functions of the job explained to you?
Yes	No	Do you understand these essential functions?
Yes	No	Can you perform the essential functions of this job with or without reasonable accommodation?

Security

		List States and counties of residence for the past seven years.


Yes	No	Have you used any names or Social Security Numbers other than given above? If so, please comment below.

Yes	No	Have you been convicted of a crime in the past 7 years? If so, Please describe in the boxes below. (Conviction will not necessarily be a bar to employmnet. In accordance with company policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)

Incident	City/State	Charge
1.
2.

Previous Employers

Note: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.
FOR EMPLOYERS OUTSIDE THE U.S. A CURRENT FAX NUMBER IS MANDATORY.

Most Recent Employer		Yes	No	Are you currently working for this employer?
		Yes	No	If yes, may we contact?
Company Name	City			State

Phone		Fax	Supervisor

Dates Employed			Job Title
From		To
Duties

Salary		Reason for Leaving
$	Per

Second Most Recent Employer		Yes	No	Are you currently working for this employer?
		Yes	No	If yes, may we contact?
Company Name	City			State

Phone		Fax	Supervisor

Dates Employed			Job Title
From		To
Duties

Salary		Reason for Leaving
$	Per

Third Most Recent Employer		Yes	No	Are you currently working for this employer?
		Yes	No	If yes, may we contact?
Company Name	City			State

Phone		Fax	Supervisor

Dates Employed			Job Title
From		To
Duties

Salary		Reason for Leaving
$	Per

References

Note: Include only individuals familiear with your work abillity. Do not include relatives.

Name	Address	Years Known/Relationship
1.
2.

Education

Note: Do not fill out any part of this section you believe to be non-job related.

Please indicate the highest grade completed.
7	8	9	10	11	12	13	14	15	16	16+

If your school records are under a different name than listed, please enter that name
Name:

High School	City/State	Graduated	Degree

College

Other

Comments

Certification and Release

I certify that I have read and understand the applicant note on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and / or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.