Pax Premium Lawn

Blank Form (#10)

APPLICATION FOR EMPLOYMENT

Date / Time

Social Security #

Date of Birth

Personal Information

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

18 Years or older? YES or NO

Legally eligible to work in US?

US Citizen? YES or NO

Ever Convicted of a Crime?

IF YES, STATE THE DATE AND PLACES WHERE THE CHARGES OCCURRED (NOTE: ANSWERING “YES” WILL NOT AUTOMATICALLY DISQUALIFY YOU FOR EMPLOYMENT):

Employment Information

Position Applying For

Date you can Start?

Salary Requirement?

Referred by? Please print name

Type of Employment (FULL - PART TIME)

Any Shifts you can not work? Why

Willing to work Over Time if required?

Ever applied to this company before? If YES give explanation below.

Presently employed? If YES may we contact present employer?

Emergency Contact Person

Name

Address

Contact Phone #

Relationship

Educational Background

High School Name - City, State

# of Years Completed

Year of Graduation

Undergraduate College - Name

# of Years Completed

Year of Graduation

Graduate College - Name

# of Years Completed

Year of Graduation

Business or Tech School

Years completed

Graduation Date

Field or Specialty

LIST ANY EXTRACURRICULAR ACTIVTIES, AWARDS, SCHOLARSHIPS. OR CLUBS THAT YOU WERE INVOLVED IN WHICH MIGHT BE RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING

Employment Experience

Please give an accurate and complete full/part time employment record of your last 3 jobs. Start with your present or most recent employer.

#1 Employer Name and Address (City, State, Zip - Phone #)

Begin Salary

Ending Salary

Manager Name - Title

Reason for Leaving

#2 Employer Name and Address (City, State, Zip - Phone #)

Begin Salary

Ending Salary

Manager Name - Title

Reason for Leaving

#3 Employer Name and Address (City, State, Zip - Phone #)

Begin Salary

Ending Salary

Manager Name - Title

Reason for Leaving

Business References

List below the names of three persons, not related to you, whom you have known for at least one year.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Work Phone

Home or Cell #

Relationship

# Years Known

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Work Phone

Home or Cell #

Relationship

# Years Known

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Work Phone

Home or Cell #

Relationship

# Years Known

PLEASE READ AND SIGN

I hereby reaffirm that I have read the foregoing questions and that my answers to them are true and correct and that I have not misrepresented or withheld any information. I understand that falsification of this information may cause immediate dismissal. I further acknowledge that my employment is “at will”. This means I am free to terminate my employment at any time, for any reason, and the company retains the same right. I understand that any offer of employment may be contingent upon a credit and criminal background investigation and a pre-employment drug screen. I hereby authorize all references and former employers listed in my employment application to give the company any and all information concerning my previous employment and any pertinent information they might have, personal or otherwise. I hereby release all parties, including agents, from any claims, causes of action, or liability from damages that may or could result from furnishing such information obtained through a background investigation or drug test.

NOTICE: APPLICATION FOR EMPLOYMENT DOES NOT CONSITUTE A PROMISE OR COMMITMENT THAT YOU WILL BE HIRED.

Signature of Applicant - Or Type

Date Signed