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Internal Office Use Only Date Area Manager Utility Company MVR Yes No Background Check Yes No EMPLOYMENT PRE-APPLICATION FALSE OR MISLEADING STATEMENTS OR WITHHOLDING REQUESTED INFORMATION IS CAUSE FOR REFUSAL TO HIRE OR LATER DISCHARGE LAST NAME FIRST NAME MIDDLE NAME CURRENT ADDRESS TELEPHONE NUMBER CITY BIRTH DATE SOCIAL SECURITY NUMBER STATE ZIP CODE DRIVER S LICENSE NUMBER STATE CLASS PLEASE LIST BELOW YOUR PREVIOUS RESIDENCE INFORMATION FOR THE LAST THREE 3 YEARS LIST MOST RECENT FIRST AND INCLUDE AS OF DATE STREET ADDRESS CITY STATE ZIP PREVIOUS EXPERIENCE IN THE TREE CARE INDUSTRY CURRENT OR PREVIOUS PLACE OF EMPLOYMENT COMPANY NAME ADDRESS CITY STATE ZIP JOB TITLE OR POSITION DATE WORKED FROM REASON FOR LEAVING HAVE YOU EVER WORKED FOR CAROLINA TREE CARE IN THE PAST NO YES IF YES LIST ALL DATES AND REASON S FOR LEAVING CONDITION OF EMPLOYMENT In consideration of my new and continued employment the company may verify the information set forth on this application and obtain additional information relating to my background and at their will and discretion may periodically review and research information relating to my background. I therefore authorize all persons schools companies corporations law enforcement agencies medical organizations and the Department of Motor Vehicles to supply any information concerning my background. APPLICANT S INITIALS I understand that as a condition of employment I will be required to submit a sample of my urine and/or blood for chemical analysis. I authorize any certified laboratory to release the results of these tests to the company. I release the company from any liability arising from this request and any decision made concerning my application for employment which may be based in whole or in part upon the result of the test analysis. I understand that the presence of any illegal or non-prescription drug or alcohol in my system will result in the denial of employment with the company or the termination of that employment. I further understand that employment with the company is conditioned upon my willingness to submit to periodic drug and/or alcohol testing required by the company and that refusal to submit or cooperate with any such testing will result in termination of employment. I therefore authorize all persons schools companies corporations law enforcement agencies medical organizations and the Department of Motor Vehicles to supply any information concerning my background. APPLICANT S INITIALS I understand that as a condition of employment I will be required to submit a sample of my urine and/or blood for chemical analysis. APPLICANT S INITIALS I understand that as a condition of employment I will be required to submit a sample of my urine and/or blood for chemical analysis. I authorize any certified laboratory to release the results of these tests to the company. I release the company from any liability arising from this request and any decision made concerning my application for employment which may be based in whole or in part upon the result of the test analysis.

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