Non DOT We are an Equal Opportunity Employer. No question on this application is intended to be discriminatory under any applicable Federal, State or Local Fair Employment Practices Law. Last Name * First Name * Middle Date * Street Address * Phone * City * State * Zip Code * Social Security Number * Have you ever been involuntarily terminated or requested to resign? * Yes No If hired, can you provide verification of your legal right to work in the United States? * Yes No If you are under age 18, do you have a work permit? * Yes No If required for the position, do you have a valid driver's license? * Yes No If hired, would you have reliable transportation to and from work? Yes No Do you have friends or relatives working for our company? * Yes No If "Yes" Name and Relationship Have you ever been convited of a misdemeanor or felony? * Yes No If Yes expound II. EMPLOYMENT INTERESTS Position Sought * Date Available * Salary Desired * Would you be willing to work overtime? * Yes No Type of Employment Desired * Regular Temporary Full-Time Part-Time Do you speak any foreign languages * If yes name them Days and hours available for work * How were your referred to our company? * Ad Employee Referral Agency Other Walk-in Where Name Name III. EDUCATION INFORMATION Elementary School Years Completed * Name/Location of School * Course of Study/Degree * High School Years Completed * Name/Location of School * Course of Study/Degree * Did you graduate? Yes No College Years Completed * Name/Location of School * Course of Study/Degree * Did you graduate? * Yes No Post Graduate Years Completed * Name/Location of School * Course of Study/Degree * Did you graduate? Yes No Business/Trade Technical * Name/Location of School * Course of Study/Degree * IV. SKILLS - If applicable for which you are applying Typing Speed * WPM 10 key by touch * Yes No PC Skills (indicate software used): * Other Office Machines/Other Equipment (Describe): * Describe background that may be related to the job desired: * Employment Information. Star with current or most recent employer Employer #1 Company Name * Phone * From Month/Year * To Month/Year * Street Address * City * Starting Pay * Ending Pay * Job Title * Supervisor Name * May we contact this Employer? * Yes No Duties * Reason for Leaving * Employer #2 Company Name * Phone * From Month/Year * To Month/Year * Street Address * City * Starting Pay * Ending Pay * Job Title * Supervisor Name * May we contact this Employer? * Yes No Duties * Reason for Leaving * Employer #3 Company Name * Phone * From Month/Year * To Month/Year * Street Address * City * Starting Pay * Ending Pay * Job Title * Supervisor Name * May we contact this Employer? * Yes No Duties * Reason for Leaving * Employer #4 Company Name * Phone * From Month/Year * To Month/Year * Street Address * City * Starting Pay * Ending Pay * Job Title * Supervisor Name * May we contact this Employer? * Yes No Duties * Reason for Leaving * I authorize any person, school, current employer (except as expressly noted), past employer(s), and organizations named in this application form (and accompanying resume or other documentation, if any) to provide relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I release all parties from all liability for any damage that may result from furnishing information and opinion to you. Initial * Draw It Clear In consideration of employment, I agree to obey the rules and standards of this company. I understand that nothing contained in this application or in the interview process is intended to create a contract between this company and myself for either employment or for the providing of any benefits. I agree that my employment is at-will and the. Terms of employment may be changed with or without cause, with or without notice, including but not limited to termination, demotion, promotion, transfer, compensation, benefits duties and location of work, at any time, for any reason, at the option of myself or this company. This constitutes my entire agreement with this company with regard to the length of my employment. Initial * Draw It Type It Clear I understand that as a condition of employment I may be required to take a post-offer/pre-employment physical examination that may include an alcohol and drug test. I further understand that at any time during my employment, I may be required to take a physical examination which may include an alcohol and drug test If management reasonably suspects a condition exists that will prevent me from performing my job in a manner that does not endanger my own health or the safety and health of others. I authorize all providers of health care who examine me to disclose to this company or its agents, all medical information revealed during such examinations. I further authorize this company to disclose such information to any other persons, if at any time my medical condition is put at issue in any proceeding by myself or others. In the event that I have a disability that will affect my ability to test, I will so Inform this company so that a reasonable accommodation can be made. This company reserves the right to require medical documentation concerning the need for accommodation. Initial * Draw It Type It Clear I understand that all offers of employment are conditioned upon my providing satisfactory documentary proof of my identity and legal right to live and work In the United States. Initial * Draw It Clear I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare under penalty of perjury that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, if discovered a later date. Initial * Draw It Type It Clear Applicant Signature * Draw It Type It Clear CONSENT TO OBTAIN AND RELEASE DRIVING RECORD INFORMATION CONSENT TO BACKGROUND INVESTIGATION This document is: 1. My consent for any state to release driving record information. 2. My consent for my employer or prospective employer, their insurance agents, assigns or insurance company to secure my driving record and detailed information. 3. The original of this document may be held by my employer, their insurance agents, assigns or insurance company and copies of this document and my motor vehicle record may be provided as necessary. 4. Consent to background investigation BY SIGNING THIS FORM, I GIVE MY CONSENT AND RELEASE AS NOTED ABOVE. THIS SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL I FILE A FORMAL WRITTEN WITHDRAWL WITH MY EMPLOYER, THEIR INSURANCE AGENTS AND THEIR INSURANCE COMPANY. Signature * Draw It Type It Clear Drivers License State of Issue * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers License Number * Date * Date of Birth * URINALYSIS AND BREATH ANALYSIS CONSENT FORM I understand that Moore's Retread & Tire Company requires pre-employment drug and alcohol testing of all applicants. I further understand that Moore's conducts random drug testing as required by law. I consent to the urine sample collection and testing for controlled substances and the breath sample collection and testing for alcohol, both pre and post-employment. I understand that a verified positive test result for controlled substances and/or alcohol concentration will render me unqualified for employment with Moore's. Results will be reported to Moore's by the independent testing facility contracted to conduct these tests. If the results are positive, the controlled substance will be identified. These results will not be released to any other parties without my written consent. Signature * Draw It Type It Clear