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Employment Application

We consider all applications for positions without regard to race, color, religion, sex, national orgin, age , verteran/reserve/national guard, or any other protected status. Equal access to programs, services and employment is available to all persons. Those applications requiring reasonable accomodations to the application and/or interview process should notify the Human Resources Department.


Name *

Phone *

Email *

Date of Application *

4/29/2017

Position Applied For *

Referral Source

Advertisement

Walk-in

Private Employment Agency

Relative

Government Employment Agency

Employee

Other

Name of source (if applicable)



Current and Prior 3 years Residence - as required by Federal and State DOT regulations section 391.21

Address *

City *

State *

Zip Code *

How Long? *

Address

City

State

Zip Code

How Long?

Address

City

State

Zip Code

How Long?

Address

City

State

Zip Code

How Long?



Have you submitted an application here before?

If yes. When?

Have you ever been employed here before?

If yes. When?

Are you legally eligible for employment in this country?

Date available for work?

Type of Employment desired

Will you relocate if job requires it?

Will you be able to meet the attendance requirements for the position?

Do you have a vaild Drivers License?

State

Expiration Date

Do you have a Commercial Drivers License?

State

Expiration Date


Please list any motor vehicle accidents/moving traffic violations in the past 3 years

Date of Occurance

Nature of Occurrence

Any Injuries Recorded

Date of Occurance

Nature of Occurrence

Any Injuries Recorded

Date of Occurance

Nature of Occurrence

Any Injuries Recorded

Date of Occurance

Nature of Occurrence

Any Injuries Recorded



Employment History

Provide complete information on your employers for the last 10 years starting with the most recent as required by Federal and State DOT regulations section 391.23(a) (2)

Employer *

Date employed from *

Date employed to *

Address *

Job Title *

Job Title From *

Job Title to *

Immediate Supervisor *

Immediate Supervisor Title *

Starting Hourly Rate/Salary *

Final Hourly Rate/Salary *

Reason For Leaving *

May we Contact for Reference?


Employer

Date employed from

Date employed to

Address

Job Title

Job Title From

Job Title to

Immediate Supervisor

Immediate Supervisor Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Reason For Leaving

May we Contact for Reference?


Employer

Date employed from

Date employed to

Address

Job Title

Job Title From

Job Title to

Immediate Supervisor

Immediate Supervisor Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Reason For Leaving

May we Contact for Reference?


Employer

Date employed from

Date employed to

Address

Job Title

Job Title From

Job Title to

Immediate Supervisor

Immediate Supervisor Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Reason For Leaving

May we Contact for Reference?



Educational Background

A. List medium-4 small-12 (4) schools attended starting with the most recent. B. Years completed C. Indicate Degree or diploma earned, if any D. Major field of Study E. Minor field of study (if applicable).

A. School *

B. Years *

C. Degree/ Diploma

D. Major field of Study *

E. Minor field of Study

A. School

B. Years

C. Degree/ Diploma

D. Major field of Study

E. Minor field of Study

A. School

B. Years

C. Degree/ Diploma

D. Major field of Study

E. Minor field of Study

A. School

B. Years

C. Degree/ Diploma

D. Major field of Study

E. Minor field of Study



References

List name and telephone number of medium-3 small-12 business/work refernces who are not related to you and are not previous supervisors. If not applicable, list medium-3 small-12 school or personal references not related to you.

Name *

Telephone *

Years Known *

Name *

Telephone *

Years Known *

Name *

Telephone *

Years Known *



Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position in which you are applying.




Additional Information

List any additional information you would like us to consider. List any professional, trade, business, or civic associations, and any offices held. Exclude any memberships which would reveal sex, race,religion, national orgin, age, color, disability, or any other similarly protected status.





Attach Resume

You may attach your resume if you would like.



Contact Us

Terry Tree Service, LLC.
225 Ballantyne Rd, Rochester NY 14623