Job Application

Employment Application

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientations, military reserve membership, ancestry, religion, height, weight, physical handicap, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on the needs of the job, you may be required to complete a medical history form and you may be required to be examined by a medical professional designated by the company.

*Today's Date

*First Name:

*Middle Initial:

*Last Name

*Home Phone

*Cell Phone

*Email

*Address:

Street, City, State, and ZIP

Prior Address

Street, City, Sate, and ZIP

*Position Applying For:

*Date Available to start

*Preferred Location:

JOB-RELATED SKILLS

NOTE: Do not fill out any part of this section you believe to be non-job related.

If the job requires, do you have the appropriate valid drivers license?

Yes No

Name on license:

DL#:

State of issue:

Have you had any moving violations?

Yes No

If yes, please describe:

Can you perform the essential functions of this job with or without reasonable accommodation?

Yes No

Security

*Have you been convicted of a crime in the past seven years?

Yes No

If so, please describe in the boxes below. (Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)

Incident:

City/State:

Charge:

Incident:

City/State:

Charge:

DRIVER EXPERIENCE & QUALIFICATIONS

**Complete this section only if applying for a driving position, or if you currently hold a commercial drivers license.

Drivers Licenses Held In Past 3 Years Must Be Shown.

License No.:

State:

Class:

Endorsements:

Restrictions:

Expiration Date:

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?:

Yes No

Has any license, permit, or privilege even been suspended or revoked?:

Yes No

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?:

Yes No

Driving Experience

Class of Equipment:

Equipment Types:

(Van, Tank, Flat, etc.)

EDUCATION

NOTE: do not fill out any part of this section you believe to be non -job related.

Name:

City/State

Graduate:

Degree:

Name:

City/State:

Graduate:

Degree:

Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company:

EMPLOYMENT HISTORY

– Please provide a minimum of 5-year employment history

MOST RECENT EMPLOYER

*Are you currently working for this employer?:

Yes No

*If yes, may we contact?

Yes No

*Employer:

Company Name, City, and Sate

*Phone:

*Dates:

Time started to end or current

*Job Title:

*Supervisor Name

*Duties:

*Salary:

Include per (hour, week, or month)

*Reason for leaving

SECOND MOST RECENT EMPLOYER

Employer:

Company Name, City, and Sate

Phone:

Dates:

Time started to end or current

Job Title:

Supervisor Name:

Duties:

Salary:

Include per (hour, week, or month)

Reason for leaving:

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives.

Name:

Address/ Phone:

Years Known/ Relationship:

Name:

Address/ Phone:

Years Known/ Relationship:

Name:

Address/ Phone:

Years Known/ Relationship:

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejections of my application or discharge at any time during my employment. I authorize the company and / or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. Furthermore, I understand that should an offer of employment be extended and accepted, such employment is “at will” and does not express or imply an employment contract.

Signature:

Date:

FAIR CREDIT REPORTING ACT DISCLOSURE AND AUTHORIZATION

Battle Creek Farmer’s Cooperative N/S (hereafter Farmers Pride) may procure a consumer report or investigative consumer report as defined in 15 USC 1681a of the Fair Credit Reporting Act (FCRA) for the purpose of evaluating the undersigns’ application for employment. Pursuant to the federal Fair Credit Reporting Act, I hereby authorize Farmers Pride and its designated agents and representatives to conduct a review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee or job applicant. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; motor vehicle records, including traffic citations and registration; and any other public records.
I, ________________________________, authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution, consumer reporting agency as defined in 15 U.S.C. 1681a(e), and other persons having personal knowledge of me to furnish Farmers Pride or its designated agents with any and all information in their possession regarding me in connection with my application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.

I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer's rights will be provided to me.

Applicants First Name:

Last Name:

Middle Name:

NOT initial - if none, mark "N/A"

Other Names Used (First):

(e.g. Maiden Name)

Last Name:

Middle Name:

NOT initial - if none, mark "N/A"

Address:

Street, City, State, and ZIP

Prior Address:

Street, City, State, and ZIP

Email Address:

Telephone:

Cell Phone:

DL State:

Exp. Date:

The undersigned’s application for employment cannot be processed by Farmers Pride until this disclosure and authorization is completed and signed.

*Signature

*Date

Security Code: