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
When can you start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If seasonal, when do you want to end?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you been an employee of Countryside Landscape or worked for Countryside through a temp agency in the past?
If yes, list dates and agency.
Do you posess a valid Driver’s License?
If no, reason why?
Do you have a valid DOT Medical card?
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.
Are you of legal age to work in the United States?
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)?

School and Training

Rows	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
2 digit month, 2 digit day, 4 digit yearDate
Employment Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
Employment Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
Employment Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
Employment Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Rows	State	Lic #	Type	Expiration date
Drivers License

Driving Experience

Rows	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)

Rows	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?
What is the expiration date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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

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