EMPLOYMENT RECORD

List last 3 jobs starting with the most recent.

EDUCATION

Check the highest education level completed.

JOB RELATED EXPERIENCE

Please list any experience, skills or certifications you have related to this job

__________________________________________________________

REFERENCES

Please list the name, phone number and relationship of three references

Have you ever been convicted of a felony?  Yes___    No___  If "Yes", please explain:________________________________________________

Is your driving record in good standing?  Yes___   No___  Please attach a current DMV Driving Record

I hereby certify that information on this application and attachments to be true and correct.  I agree that any misrepresention or omission of facts will invalidate my application; and should I be hired, the aforementioned may be sufficient cause for my dismissal.

I understand and agree that employment is for no definite period and may be terminated at any time without prior notice.  I further agree that the company has the right to release any information concerning my employment including, but not limited to my character, habits, abilities, and cause of separation; and I release the company from any and all liability concerning such information.

AUTHORIZATION AND RELEASE

Any Past or Present Employer, Supervisor or Co-worker, Former or Present Neighbors, References, or Institutions, U. S. Armed Forces, U. S. Selective Service System, Maritime Service, State Motor Vehicle Departments, OR

Any Academic Dean, Registrar, Principal, Guidance Counselor, other authorized person at a School (college, business, trade or high school ) OR

Any Credit Reporting Agencies or Retail Merchants Association, OR

Any County, City, State or Federal Law Enforcement Agency, Clerk or other authorized person at any County, City, State or Federal court.

I, ______________________________________, am aware that my background may be investigated in connection with my application for employment and /or during my employment by Champion Land & Lawn, and I hereby authorize and request the release of any and all information you have concerning me to Champion Land & Lawn.

I hereby release Champion Land & Lawn and its respective officers, directors, employees, representatives and agents from any liability for damage of whatever kind to me, my family, heirs or associates as a result of such background investigation or aas a result of my being granted or denied employment.

Date:_____________________________________   Signature:_______________________________________

Champion Land & Lawn IS AN EQUAL OPPORTUNITY EMPLOYER.