Personal Information:                                                                             Required Fields
                                                                    
Date    (mm/dd/yy)

Name (Last Name First)

Present Address 

           City      State       Zip Code

Phone Number       

How did you hear about us?

Email Address 

Employment Desired:

Position      Date You Start   (mm/dd/yy)

Wage Desired /wk.    Are You Employed   Yes   No

If so, may we inquire of your current employer?  Yes    No 

If yes, current employers company name, supervisor and phone number?

Education History:

                                  Name &                      Years        Did You                  Subjects
                           Location of School         Attended    Graduate?               Studied     
Elementary:                Yes   No

High School:               Yes No

College:                      Yes No

Other:                         Yes No

Certifications & Year Completed: 
                        

General Information:

Subjects of Special Study/Special Training/Skills:

                    

U.S. Military       Rank 

Did you receive an honorable discharge?  Yes   No

Former Employment:             (List Below Last Employers, Starting With Last First)

    Dates:           Name/Address Employer         Salary  Position          Reason For Leaving

References:          Give below the names of three persons not related to you, whom you
                                  have known at least one year and a phone number to contact them.

Name                      Phone Number     Relationship to you                                Years Known



Authorization:

 “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize the investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release McCoy Landscape Services, Inc. from all liability for any damage that may result from utilization of such information.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

Name:      Date: (mm/dd/yy)