Employment Application & Personnel Record Form - EEO Employer

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EMPLOYMENT APPLICATION & PERSONNEL RECORD FORM
EEO EMPLOYER
Home Office Use
Background
Clock No.
Organization Code
Name:
First
Middle
Last
Address:
Street/RFD/Box
City/Town
State
Zip Code
Social Security No. __________/_____/__________
Home Telephone No. (_____)_________-________
Are you 18 years old or older?
Yes
No
In case of emergency, contact:
:
Name:
Telephone
:
Name:
Telephone
Name and Address
Last Grade
Degree
Complete
Earned
Primary Education (Elementary/High)
Vocational/Technical
College/University
.
Employment History
List Three Most Recent Positions Held (Starting with last position held)
Company Name
Dates
Position
Reason for
Name of
Address/ Phone Number
From – To
Held
Leaving
Supervisor
References
Name:
Address & Telephone
Occupation
Relationship
1.
2.
3.
EMPLOYMENT APPLICATION & PERSONNEL RECORD FORM
EEO EMPLOYER
Home Office Use
Background
Clock No.
Organization Code
Name:
First
Middle
Last
Address:
Street/RFD/Box
City/Town
State
Zip Code
Social Security No. __________/_____/__________
Home Telephone No. (_____)_________-________
Are you 18 years old or older?
Yes
No
In case of emergency, contact:
:
Name:
Telephone
:
Name:
Telephone
Name and Address
Last Grade
Degree
Complete
Earned
Primary Education (Elementary/High)
Vocational/Technical
College/University
.
Employment History
List Three Most Recent Positions Held (Starting with last position held)
Company Name
Dates
Position
Reason for
Name of
Address/ Phone Number
From – To
Held
Leaving
Supervisor
References
Name:
Address & Telephone
Occupation
Relationship
1.
2.
3.
Check all boxes for which you have experience:
Administrative Office Positions Only
Calculator
Data Entry
Multi-Line Phone System – Number of lines
Typing
WPM
Copy Machine
Customer Service Call Handling
Computer Skills Please List Hardware & Software:
Production Skills (All Production Positions
Tree climbing
Stump grinder
Chain saw
Spraying
Chipper
Bucket truck
Other
Do you have any other experience doing tree work?
Yes
No
If your answer is yes, please describe any additional training, experience and the total number of years
Experience that you have:
Are you trained in line clearance tree trimming?
Yes
No
If your answer is yes, when?
By whom?
Do you have practical experience in line clearance tree trimming?
Yes
No
If your answer is yes,
How long?
Where?
Driving Skills (Driving Positions only, must be 21 years of age or older)
Commercial Driver's License:
Yes
No
____________/_____________________
Check all those that you have experience operating.
State
Number
Automatic transmission
Two-speed rear axle
Truck and chipper
Manual multi-speed Trans.
1-ton truck
Bucket truck
2-ton truck
Vehicle accident record for past 3 years or more (attach sheet if more space is needed)
Driving positions only, do not disclose your own injuries.
Date
Nature Of Accident
Fatalities
Injuries
(Head-On, Rear-End, Etc)
To Others
Last Accident
Next Previous
Next Previous
Traffic convictions for the past 3 years (other than parking violations)-Driving Positions Only
Conviction
Date
Charge
Penalty
(Attach sheet if more space is needed)
Federal DOT regulations require checks on all drivers
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
B. Has any license, permit or privilege ever been suspended or revoked?
Yes
No
If the answer to either A or B is yes, attach statement giving details.
Ability to Perform Essential Functions of the Job (All Production Positions): All production positions are physically demanding. Entry-level
Employees in these positions are expected, within a reasonable time after they commence employment, to be able to do tree work. This work
includes climbing trees and removing tree limbs using various hand and power tools on a continuous basis during an eight to ten hour shift;
removing and disposing of tree limbs using various mechanized tools, which can require lifting and carrying from 50- to 100-pound loads.
Most entry-level employees may also be required to obtain state licenses to apply pesticides and engage in duties that require exposure to
various chemicals and pesticides. Are you physically able to safely perform these job duties with or without a reasonable accommodation?
Yes
No
Please Read Carefully
Application Verification and Acknowledgement
I certify that the information contained in the application is correct to the best of my knowledge and understand that falsification of this
information may result in refusal to hire or, if hired, dismissal. I authorize any of the persons or organizations referenced in this application to
give you any and all information concerning my previous employment, education, or any other information they might have, personal or
otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may
result from furnishing such information to you. I authorize you to request and receive such information, in the process of my being
considered for employment by your company. I agree to conform to the guidelines of the company and acknowledge that these guidelines
may be changed, interpreted, withdrawn, or added to by your company's sole option and without any prior notice to me. I further
acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without
cause, and with or without any prior notice at any time, at the option of the company or myself. I understand that no representative of the
company has any authority to enter into any agreement for employment for any specified period of time, or assure or make some other
personnel move, either prior to or after commencement of employment or make any agreement contrary to the foregoing unless in writing,
signed by the president of the company. I acknowledge that I have been advised that this application will remain for no more than 90 days
from the date it was made. I understand that any handbook or memorandum or other writing given to me shall not constitute express or
implied contract of employment.
I understand and acknowledge that any offer of employment is expressly conditioned upon my completion of a pre-employment medical
questionnaire, a review by the company's physicians of responses to that questionnaire and any other medical records that the company may
wish to obtain, satisfactory completion of any medical examinations that may be required by the company, and a determination by the
company that I am qualified to safely perform the job sought without a significant risk of future injury. I further understand that even though
this review process may take several weeks, any offer of employment remains conditional until it has been approved by the company's
personnel officer.
Applicant’s signature
Date
Applicant: DO NOT WRITE ON THIS PAGE
Interviewer's Comments
:
To be completed by crew leader/supervisor, only after employee is hired,
Organization Code: __________/__________/__________ Starting Date: __________________________
Occupation Code/Description: ____________________________________________________________
Rate of Pay per hr/wk: _____________________________ Date of Birth___________________________
Sex:
M
F
Race:
White
Black
Hispanic
Asian
American Indian
Comments:
Federal law forbids discrimination based on age, sex, race, religion, national origin, physical or mental handicap
or disability. This information is obtained solely for federal statistical reporting requirements. Obtain date
of birth from employee and circle employee's race and sex from visual observation.
Crew Leader's or Supervisor's Signature
Date

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