APPLICATION TIRE DISCOUNTERS, INC.

We consider applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Position(s) Applied For:

Date of Application:

How Did You Learn About Us?
Advertisement	Friend	Inquiry	Web Search	Relative	Other

Last Name	First Name	Middle Name

Street	City	State	Zip Code	County

Telephone Number(s)	Social Security Number

Only U.S. Citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? Yes No

If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No
Have you ever filed an application with us before?
Yes No	If yes, give date:
Have you ever been employed with us before?
Yes No	If yes, give date:
Do any of your friends or relatives work here?
Yes No	If yes, state name, relationship, and work location

Date available for work:

Desired salary: per

(hour week year)

Are you available to work:

Full Time	Overtime # hours per week:
Part Time	Temporary (Dates available from to )

Please indicate days and times you’re available to work:

DAY	MON	TUE	WED	THUR	FRI	SAT
AM
PM

Do you have reliable transportation? Yes No

Can you travel if the job requires it?

For positions that require driving:

Do you have a valid driver's license? Yes No Driver’s Lic. #

Have you been convicted of any moving violations in the past five years? Yes No

If yes, please explain:

Have you been convicted of a felony within the last seven (7) years? Yes No

(A conviction will not necessarily disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)

If yes, please explain:

Are you capable of performing the duties involved in the position for which you have applied with or without a reasonable accommodation? Yes No

EDUCATION

School	Name of School City, State	Course of Study	Years Completed	Diploma/ Degree
High School
College
Other

EMPLOYMENT EXPERIENCE

Begin with current or most recent employer. Do not exclude any employment. Include any applicable temporary employment, job-related military service assignments and volunteer activities. Exclude organizations which indicate race, color, religion, gender, national origin, disabilities, age or other protected status.
Employer	Dates Employed		Worked Performed
Address	From	To
Telephone Number(s)	Hourly Rate/Salary
Job Title	Starting	Final
Supervisor
Reason for Leaving		May we contact? Yes No

Employer	Dates Employed		Worked Performed
Address	From	To
Telephone Number(s)	Hourly Rate/Salary
Job Title	Starting	Final
Supervisor
Reason for Leaving		May we contact? Yes No

Employer	Dates Employed		Worked Performed
Address	From	To
Telephone Number(s)	Hourly Rate/Salary
Job Title	Starting	Final
Supervisor
Reason for Leaving		May we contact? Yes No

Please explain any gaps in employment:

ADDITIONAL INFORMATION

State any additional information you feel may be helpful to us in considering your application, including any job-related training in the U.S. Military:

REFERENCES

(DO NOT INCLUDE FAMILY MEMBERS OR PAST SUPERVISORS THAT ARE LISTED ABOVE)

Name	Phone Number	Occupation	Years Known
1.
2.
3.

APPLICANT’S STATEMENT – PLEASE READ CAREFULLY BEFORE SUBMITTING

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Tire Discounters that such employment with Tire Discounters is at will, for no specified duration and may be terminated by either Tire Discounters or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Tire Discounters or its representatives used during the employment process is deemed a contract of employment real or implied.

In consideration for employment with Tire Discounters, if employed, I agree to conform to the rules, regulations, policies and procedures of Tire Discounters at all times and understand that such obedience is a condition of employment. I understand that due to the nature of tire retail business, attendance and punctuality are considered essential requirements of every job at Tire Discounters and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with Tire Discounters, I will be required to submit to drug screening and background check (including a motor vehicle report for positions that require driving) as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Tire Discounters and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

By submitting this application, I acknowledge that I have read, understood and agree to the above statements.

Drug Free Work Place