CSL Application for Employment

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Position applied for*
Expected pay *
Full time or part time*

Full timePart time
When can you start?*

MonthDayYear
Date
If seasonal, when do you want to end?

MonthDayYear
Date
Have you been an employee of Countryside Landscape or worked for Countryside through a temp agency in the past?*

YesNo
If yes, list dates and agency.
Do you posess a valid Driver’s License?*

YesNo
If no, reason why?
Do you have a valid DOT Medical card?*

YesNo
Special training or skills that would be helpful to perform work you are applying for?
Are you legally eligible for employment in the United States? If yes, proof is required.*

YesNo
Are you of legal age to work in the United States?*

YesNo
Do you have any existing injuries or conditions that will prohibit you from performing the duties of the position you are applying for?
Are you capable of repeatedly lifting over 75 pounds, bending, pulling, stretching (if applying for landscape crew position)?*

YesNo

School and Training*

	Major/Field of Study	Did you Graduate?	Degree/Diploma
High School
College
Graduate School
Vocational
Training
Other Training

Membership in professional or civic organization?
EMPLOYMENT HISTORY

Please list in chronological order, beginning with most recent
Employer*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Job Title*
Employment Starting Date*

MonthDayYear
Date
Employment Ending Date*

MonthDayYear
Date
Work Duties*
Reason for Leaving*
Employer
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Job Title
Employment Starting Date

MonthDayYear
Date
Employment Ending Date

MonthDayYear
Date
Work Duties
Reason for Leaving
Employer
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Job Title
Employment Starting Date

MonthDayYear
Date
Employment Ending Date

MonthDayYear
Date
Work Duties
Reason for Leaving
Employer
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Job Title
Employment Starting Date

MonthDayYear
Date
Employment Ending Date

MonthDayYear
Date
Work Duties
Reason for Leaving
REFERENCES

Please do not include family members
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
DRIVING EXPERIENCE

Drivers License*

	State	Lic #	Type	Expiration date
Drivers License

Driving Experience*

	Type (Van, Tank, Flat, Etc.)	Dates From	Dates To	Approx # of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor _Two Trailers
Other

Accident Record for the past 3 years (attach sheet if more space is needed)*

	Date	Nature of Accident (Head on, Rear end, upset)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous

Do you possess a Valid DOT Medical Card?*

YesNo
What is the expiration date?

MonthDayYear
Date

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)*

	Location	Date	Charge (Yes or No - Description if Yes)	Penalty (Yes or No - Description if Yes
Last
Next Previous
Next Previous

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YesNo
B. Has any license, permit, or privilege been suspended or revoked?*

YesNo
If the answer to either A or B is yes, please give details
VALID DRIVER'S LICENSE, DOT MEDICAL CARDS AND DOT DRUG & ALCOHOL TESTING (CDL DRIVERS ONLY) ARE MANDATORY FOR EMPLOYMENT
Countryside Landscape & Design Inc is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran or disabled status, or genetic information.
By submitting this application you acknowlege to have completed this application truthfully to the best of your knowlege. This application is not binding either to yourself or to Countryside Landscape.
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