Landmark Services Cooperative

EMPLOYMENT APPLICATION

Position Applied For: ___________________________________________________

Interested In: Full Time Part-Time Seasonal Internship

PERSONAL INFORMATION

Last Name

First Name Middle

Address

City State Zip Code

Phone

Email Address

Are you at least 18 years of age? (If not, you will be required to provide a copy of your work permit.)

YES

NO

Can you provide documentation to verify your identity and legal authority to work in the united states?

YES

NO

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or a felony, or been convicted

in a military court martial? YES NO

(A yes answer to the above question does not necessarily disqualify an applicant from employment.) If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________

Have you been employed by Landmark Services Cooperative before? YES NO

If yes, when? ________/________/_______ - ________/________/______

How did you hear about Landmark employment opportunities?

www.landmark.coop

Online Job Posting: _____________

Newspaper:______________

Employee Referral:______________________

Other:________________________________

EDUCATION INFORMATION

Circle Highest

Grade Completed:

High School: 1 2 3 4

College: 1 2 3 4

H.S. Diploma

GED

Certificate

Associates

Bachelors

Masters

PHD

Major:____________________

Minor:____________________

EMPLOYMENT INFORMATION

Please provide the following information on all employers during the previous 3 years, beginning with your most recent. If you were self-employed, give firm name. You must give the same information for all employers you have driven a

commercial motor vehicle for the 7 years prior to the initial 3 years (total of 10 years employment record). Attach additional sheets if necessary.

Have you ever been dismissed, or asked to resign, from any position? YES NO

Name of Employer:______________________________________________________________________________ Job Title:_________________________________________________________________________ Start Date: ________/________/_______ End Date: _________/_________/_________ Supervisor’s Name and Title: ______________________________ Address:_________________________________________________________________________ Telephone Number(______)________-____________ Reason for leaving or wanting to leave:____________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

Name of Employer:______________________________________________________________________________ Job Title:_________________________________________________________________________ Start Date: ________/________/_______ End Date: _________/_________/_________ Supervisor’s Name and Title: ______________________________ Address:_________________________________________________________________________ Telephone Number(______)________-____________ Reason for leaving or wanting to leave: ___________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

Name of Employer: _____________________________________________________________________________ Job Title:_________________________________________________________________________ Start Date: ________/________/_______ End Date: _________/_________/_________ Supervisor’s Name and Title: ______________________________ Address:_________________________________________________________________________ Telephone Number(______)________-____________ Reason for leaving or wanting to leave: ___________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

CERTIFICATION AND TERMS

I certify that all of the information I have given in completing this application is true and complete. I

further understand that Landmark Services Cooperative may refuse employment or discharge me

during employment if I have given false or misleading information or omissions in this application.

In signing this application, I give my permission to Landmark Services Cooperative to perform an

investigation either by direct or indirect means that may involve all or some of the following:

previous employment, education, credit record***, driving record, criminal history, and skill

verification. I further authorize any individual, previous employer, institution, or company to provide

such information and release such party(s) including Landmark Services Cooperative from any and

all liability that might otherwise be incurred in furnishing such information, subject to federal and

state law.

I understand and agree that if employed, the employment will be “at will”. This means that either

Landmark Services Cooperative or I may end the employment relationship at any time, for any

reason, or no reason. I further understand that receipt of this application by Landmark Services

Cooperative does not imply employment nor is this application a contract of employment. I

understand that no Landmark Services Cooperative representative has the authority to alter the “at

will” nature of this employment absent written authorization of the C.E.O.

I further understand that if employed, I may be required to voluntarily submit to a drug test as

directed by Landmark Services Cooperative for any of the following: (a) a drug/alcohol screening

after hire but before starting work, (b) a random drug/alcohol test legally required in your job, e.g.

DOT, (c) a random drug/alcohol test as required by Landmark Services Cooperative, (d) a

drug/alcohol test after involvement in an “on the job” industrial or vehicular accident, (e) a

drug/alcohol test after an occurrence of “probable cause”. If I refuse to take a drug/alcohol test, I

understand that an offer of employment may be withdrawn or my employment terminated by

Landmark Services Cooperative.

***If a credit report is requested and information on that report is used by the Company, which adversely

affects you, the Company will furnish you with a copy of that report and your rights under the “Fair Credit

Reporting Act.”

_________________________________________ _________/_________/_______

Signature Date

_________________________________________

Please Print your Name

DIVERSITY QUESTIONNAIRE (VOLUNTARY)

DATE:____________________

COMPLETION OF THIS PAGE IS VOLUNTARY

Thank you for considering Landmark Services Cooperative as an employer. Landmark gives full consideration for

employment to all qualified individuals regardless of race, color, gender, age, sexual orientation, national origin,

religion, disability, or veteran status. Enclosed is the Employment Application for consideration of employment and

the Diversity Questionnaire. Federal regulations require the identification of gender and race of our applicants. The

following information will assist us in complying with government – required record keeping. This information is not

part of the employment application or selection process and will be processed separately. Providing this

information is strictly on a voluntary basis. If you choose to provide the information, please complete the

following questionnaire.

Gender: Male

Female

Referral Source: (Choose only one)

Walk- In

Mail Employee Referral

External Recruiting Agency Print Advertisement

Please Specify:

Online

Please Specify:

Unknown

Race: (Choose only one)

Hispanic or Latino

White

Black or African

American

Native Hawaiian or

Other Pacific Islander

Asian

American Indian or

Alaska Native

Two or More Races

Unknown

Instructions for completing the Applicant Diversity Questionnaire 1. Check “Gender” and “Referral Source”.

2. Check the appropriate box for Race using the

following definitions: Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American India or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.