APPLICATION
424 Bunker Hill Road, Strasburg, PA 17579 717-687-4271 - 717-687-4272 (fax) - info@countrysideroof.com
We are an Equal Opportunity Employer:
Personal Information:
Your Name:
Street:
City:
State:
Zip:
Phone Number:
Email Address:
Social Security Number:
Drivers Liscence Number:
Are you a U.S. Citizen?	Yes No
If no are you authorized to work in the U.S.?	Yes No
Are you 18 years or older?	Yes No
Have you ever been arrested and convicted of a felony?	Yes No
Do you currently have a valid drivers liscence?	Yes No
ANSWER ALL QUESTIONS OR YOU WILL NOT BE CONSIDERED FOR EMPLOYMENT:
Employment Desired:
Position Applying For:
Wage/ Salary Expected:
How did you hear about us?
Have you ever been employed by Countryside Roofing & Exteriors?	Yes No
If yes, when?
Have you ever applied to Countryside Roofing & Exteriors previously?	Yes No
If yes, when?
Do you have any medical or physical conditions that require special accomodations?	Yes No
If yes, explain:
Education:
HIGH SCHOOL:
Name of School:
Location of School:
# of Years Attended:	Graduate?Yes No
Subjects Studied:
COLLEGE:
Name of College:
Location of College:
# of Years Attended:	Graduate?Yes No
Subjects Studied:
TRADE, BUSINESS, CORRESPONDENCE SCHOOL:
Name of School:
Location of School:
# of Years Attended:	Graduate?Yes No
Subjects Studied:
OTHER ADULT EDUCATION:
Name of School:
Location of School:
# of Years Attended:	Graduate?Yes No
Subjects Studied:
Employment History:
MOST RECENT EMPLOYER:
Name of Employer:
Location:
Dates of Employment:	from: to:
Salary/Wage:
Position:
Reason for Leaving:
PREVIOUS EMPLOYER:
Name of Employer:
Location:
Dates of Employment:	from: to:
Salary/Wage:
Position:
Reason for Leaving:
PREVIOUS EMPLOYER:
Name of Employer:
Location:
Dates of Employment:	from: to:
Salary/Wage:
Position:
Reason for Leaving:
References:
Please give the names of three individuals whom you have known for at least one year. (NO RELATIVES PLEASE).
Reference 1:
Reference 1 Phone:
Reference 2:
Reference 2 Phone:
Reference 3:
Reference 3 Phone:
CERTIFICATION:
"I certify that 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 investigation of all statements contained herein, the references listed above as well as a criminal back ground check to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same to you. I further understand my employment is contingent upon the above mentioned investigation results." "I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause."
I Agree I Do Not Agree