Employment Application & Personnel Record Form - Eeo Employer (Page 3 of 4) in pdf

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

Yes

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

Yes

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

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may be changed, interpreted, withdrawn, or added to by your company's sole option and without any prior notice to me.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acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without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

Employment Application & Personnel Record Form - Eeo Employer Page 3