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Employment Application

Step 1 of 5

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Personal Information
Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Enter Email Confirm Email
Phone*
Are you 18 or older?*
- Yes
- No
Are you a U.S. citizen?*
- Yes
- No
Do you have U.S. military experience?*
- Yes
- No
Date entered*
Date Discharged*
Honorable?*
Are you lawfully entitled to be employed in the US?*
- Yes
- No
Have you ever been convicted of a crime?*
- Yes
- No
If yes, please state citation, date and place where it occurred*

Employment History
Do you have previous employers?*
- Yes
- No
Previous Employer #1*
Employer #1: Phone*
Employer #1: Address*
Street Address City State ZIP Code
Employer #1: Supervisor*
Employer #1: Job Title*
Employer #1: Starting & Ending Salary*
Employer #1: Job Responsibilites*
Employer #1: Worked From / To*
Employer #1: Reason for Leaving*
Are there additional employers? 1*
- Yes
- No
Previous Employer #2*
Employer #2: Phone*
Employer #2: Address*
Street Address City State ZIP Code
Employer #2: Supervisor*
Employer #2: Job Title*
Employer #2: Starting & Ending Salary*
Employer #2: Job Responsibilites*
Employer #2: Worked From / To*
Employer #2: Reason for Leaving*
Are there additional employers? 2*
- Yes
- No
Previous Employer #3*
Employer #3: Phone*
Employer #3: Address*
Street Address City State ZIP Code
Employer #3: Supervisor*
Employer #3: Job Title*
Employer #3: Starting & Ending Salary*
Employer #3: Job Responsibilites*
Employer #3: Worked From / To*
Employer #3: Reason for Leaving*

Work Desired
Position Requested
Date you can start
Full-time
- Yes
- No
Part-time
- Yes
- No
Wage desired
Are you employed now?
- Yes
- No
Where?
May we contact your employer?
- Yes
- No
Are there any hours or days of the week you cannot work?
- Yes
- No
If so, when?
Please provide any additional information such as special skills, training, management experience, equipment operation or qualifications you feel will be helpful to us in considering your application:

Education
If in school, current grade
Name of school
If out of school, highest grade completed: (choose one)*
Name of school last attended
Do you have any health restrictions?
- Yes
- No
If so, please state:
Emergency contact
Name Phone
Do you have a farm background?
- Yes
- No
What farm equipment can you operate?
Comments

Employment Confirmation
In submitting this application, you hereby agree to the following authorization:

Authorization:
I understand that, prior to being offered employment, I may be requested to take an employment examination. In the event that I have a disability that will affect my ability to take the test, I will so inform the Company prior to the test so that a reasonable accommodation can be made. The Company reserves the right to require medical documentation regarding the need for accommodation. “I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be grounds for termination. I authorize investigation of all statements contained in this application for any employment-related purpose. I release the listed references & all employers to Lewis Farm Market with any information that they may have & give to this Company.

I declare that the above information is true and accurate,
and agree to the terms of employment as shown above authorization.
Name
This field is for validation purposes and should be left unchanged.

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Farm Address: 4180 West M-20, New Era, Michigan 49446 — (231) 861-5730
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