Application

SOUTHERN TIER SECURITY, INC
APPLICANT INFORMATION
Last Name *
First *
M.I. *
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
E mail Address *
example@example.com
Date of Birth *

Month Day Year
Date
Social Security No. *
Desired Salary *
Position Applied for *
Are you a citizen of the United States? *

Yes No
If no, are you authorized to work in the U.S.? *

Yes No
Have you ever worked for this company? *

No Yes
Have you ever been convicted of a crime? *

No Yes
Do you currently have a NYS Security Guard License? *

No Yes, if yes enter number below
Do you have a VALID NYS pistol permit? *

No Yes
Do you currently have a PA Security Guard, Art. 235? *

No Yes
Do you have a VALID PA pistol permit? *

No Yes
Do you have a state issued Driver's License? *

No Yes
EDUCATION
High School *
Address *

Street Address

Street Address Line 2

City State
FROM? *

Month Day Year
Date
TO? *

Month Day Year
Date
Did you graduate? What degree? *

No Yes
College
Address

Street Address

Street Address Line 2

City State
FROM?

Month Day Year
Date
TO?

Month Day Year
Date
Did you graduate? What degree?

No Yes
Other
Address

Street Address

Street Address Line 2

City State
FROM?

Month Day Year
Date
TO?

Month Day Year
Date
Did you graduate? What degree?

No Yes
REFERENCES
Please list TWO professional references.
Full Name *
Relationship *
Company *
Phone Number *
Please enter a valid phone number.
Address *
Full Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Full Name
Relationship
Address
Phone Number
Please enter a valid phone number.
PREVIOUS EMPLOYMENT
Company *
Phone *
Address *
Supervisor *
Job Title *
Starting Salary *
Ending Salary *
Reason for Leaving *
May we contact your previous supervisor for a reference? *

YES NO
Responsibilities *
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From

Month Day Year
Date
To

Month Day Year
Date
Rease for Leaving
May we contact your previous supervisor for a reference?

Yes No
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Date

Month Day Year
Date
Date

Month Day Year
Date
Reason for Leaving
May we contact your previous supervisor for a reference?

Yes No
MILITARY SERVICE
Branch
From

Month Day Year
Date
To

Month Day Year
Date
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. This application will be valid for ninety (90) days. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature *

Clear
Date *

Month Day Year
Date
Whencomplete sign and return to HR@southerntiersecurity.netor fax to 716-809-8218
AUTHORIZATION TO RELEASE INFORMATION
From (your name) *
To (leave blank)
Address (leave blank)
I have applied for a position with SOUTHERN TIER SECURITY, Inc.

I have been requested to provide information for their use in reviewing my background and qualifications. Therefore, I hereby authorize the investigation of my past and present work, character, education, military and employment qualifications.

The release in any manner of all information by you is hereby authorized whether such information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information.

This authorization is valid for 120 days from date below.

Please keep this copy of my release request for your files. Thank you.
Your Signature *

Clear
Date *

Month Day Year
Date
Witness Signature

Clear
Date

Month Day Year
Date
Should be Empty:

SOUTHERN TIER SECURITY, INC

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

AUTHORIZATION TO RELEASE INFORMATION