Employment

Background

Name

First

Middle

Last

Address

Street/RFD/Box

City/Town

State

Zip Code

Social Security No

Telephone No

E-Mail

Are you 18 years old or older?

—Please choose an option—YesNo

If so, date of birth

Name

Relationship

Phone

High-School	Name	Address	Last Grade Completed	Degree Earned
Vocational/Technical	Name	Address	Last Grade Completed	Degree Earned
College/University	Name	Address	Last Grade Completed	Degree Earned

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Employment History

List Three Most Recent Positions Held (Starting with last position held)

Name

Address

Phone

Dates (From-To)

Position Held

Name of Supervisor

Salary

Reason for Leaving

Name

Address

Phone

Dates (From-To)

Position Held

Name of Supervisor

Salary

Reason for Leaving

Name

Address

Phone

Dates (From-To)

Position Held

Name of Supervisor

Salary

Reason for Leaving

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References

1	Name	Address	Telephone	Occupation	Relationship
2	Name	Address	Telephone	Occupation	Relationship
3	Name	Address	Telephone	Occupation	Relationship

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Production Skills (All Production Positions)

Tree Climbing	—Please choose an option—YesNo	Stump Grinder	—Please choose an option—YesNo	Chainsaw	—Please choose an option—YesNo	Spraying	—Please choose an option—YesNo
Chipper	—Please choose an option—YesNo	Bucket Truck	—Please choose an option—YesNo	Other	—Please choose an option—YesNo

Are you trained in tree trimming?	—Please choose an option—YesNo
When	By Whom
Do you have practical experience in tree trimming?	—Please choose an option—YesNo
How Long	Where

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Driving History

Last Accident	Nature Of Accident (Head-On, Rear-End, Etc)	Fatalities	Injuries To Others
Next Previous	Nature Of Accident (Head-On, Rear-End, Etc)	Fatalities	Injuries To Others
Next Previous	Nature Of Accident (Head-On, Rear-End, Etc)	Fatalities	Injuries To Others

Conviction #1	Date	Charge	Penalty
Conviction #2	Date	Charge	Penalty
Conviction #3	Date	Charge	Penalty

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?	—Please choose an option—YesNo
B. Has any license, permit or privilege ever been suspended or revoked?	—Please choose an option—YesNo
C. Have you ever been convicted of a felony?	—Please choose an option—YesNo
D. Can you stand for long periods of time?	—Please choose an option—YesNo
E. Can you bend and lift without pain?	—Please choose an option—YesNo
F. Can you lift 100 lbs to a height of at least 4 ft.?	—Please choose an option—YesNo
G. Can you tolerate outdoors for long periods of time?	—Please choose an option—YesNo
H. Can you hear verbal instructions from a distance?	—Please choose an option—YesNo
I. Are you physically qualified to obtain a CDL?	—Please choose an option—YesNo

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Other Questions

1. Do you hold a valid driver’s license?

—Please choose an option—YesNo

If So

Lic #

State

Class

2. Are you able to drive a standard shift? ?	—Please choose an option—YesNo
3. Do you have reliable transportation to and from work?	—Please choose an option—YesNo
4. Position desired?
5. Salary requirements, if any?
6. How did you hear about job?
7. Were you referred by a Crescent City Tree employee?	—Please choose an option—YesNo
If so, by whom?
8. Date available to start work?
9. Activities/Hobbies?

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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 may include 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?

—Please choose an option—YesNo

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Application Verification and Acknowledgement - Please Read Carefully

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 owner 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 understand that the company will require pre-employment and random drug testing. I understand and consent to a background and motor vehicle record check. 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.

Are you physically able to safely perform these job duties with or without a reasonable accommodation?

—Please choose an option—YesNo

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