| Name: | |
| Present Address:
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City:
State:
ZIP:
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| Email: | |
| Phone number: | |
| Are you 18 or older?
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| Are you a U. S. Citizen? Yes
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| Do you have U. S. Military experience?
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| Date Entered:
Date Discharged:
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| Are you lawfully entitled to be employed in the U. S.?
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| Have you ever been convicted?
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If yes, please state citation, date and place where it occurred:
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| Have you ever been tested positive for HIV?
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| Employment desired: |
| Position: | |
| Date you can start: | |
| Full-time:
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Part-time:
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| Wage desired: | |
| Are you employed now?
| Where: |
| May we contact your employer?
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| Are there any hours or days of the week you cannot work? |
| If so, when:
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| 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: |
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| Education: |
| If in school,current grade:
| Name of school:
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If out of school, highest grade completed: (check one)
yrs College
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| Name of school last attended: | |
| References: Please list 3 individuals, not related to you, whom you have known for at least 1 year: |
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Reference Name |
Phone |
Number of Years Known You |
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| Reference #1: |
| Reference #2: |
| Reference #3: |
| Do you have any health restrictions: |
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| If you please state: | |
| Date of Birth: | |
| Emergency contact-- Name:
Phone:
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| Do you have a farm background? | |
| What farm equipment can you operate? | |
Comments:
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Employment Confirmation |
| In submitting this application, you hereby agree to the following authorization: |
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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.
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I declare that the above information is true and accurate,
and agree to the terms of employment as shown above authorization.
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