OrlandHR\HR\Forms\Applications\Application for Employment Original 2008 Rev.5 – 5/4/2015

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER PERSONAL INFORMATION

NAME (LAST NAME FIRST) DATE

PRESENT ADDRESS CITY STATE ZIP CODE

PHONE NO REFERRED BY

HOW DID YOU HEAR ABOUT US? NEWSPAPER BILLBOARD FAMILY/FRIEND JOB FAIR SIGN OUT FRONT OTHER: DO YOU HAVE RELATIVES OR FRIENDS WHO WORK FOR THIS COMPANY?

YES

NO

IF YES, WHO AND WHERE DO THEY WORK?

EMPLOYMENT DESIRED

SHIFT PREFERENCE 1ST 2ND

DATE YOU CAN START SALARY DESIRED

ARE YOU OVER THE AGE OF 18? YES NO IF NO, YOU MAY BE REQUIRED TO PROVIDE AUTHORIZATION TO WORK ARE YOU CURRENTLY EMPLOYED? YES NO IF YES, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? YES NO EVER APPLIED TO THIS COMPANY

BEFORE?

YES NO

WHERE? WHEN?

ARE YOU LEGALLY ELIGIBLE TO WORK

IN THE US?

YES NO (PROOF OF IDENTITY AND ELIGIBILITY WILL BE REQUIRED FOR EMPLOYMENT) HAVE YOU EVER BEEN CONVICTED OF

A FELONY?

YES NO

WHERE & WHEN? * ANSWERING YES DOES NOT EXCLUDE YOUR APPLICATION FROM CONSIDERATION.

EDUCATION HISTORY

NAME & LOCATION OF SCHOOL YEARS ATTENDED GRADUATED SUBJECTS STUDIED ELEMENTARY SCHOOL

HIGH SCHOOL

COLLEGE, TRADE, BUSINESS OR

CORRESPONDENCE SCHOOL

GENERAL INFORMATION

SUBJECTS OF SPECIAL STUDY, ON THE JOB TRAINING, OR SPECIAL TRAINING / CERTIFICATES FROM PREVIOUS EMPLOYMENT US MILITARY OR NAVAL SERVICE

YES

NO

RANK

FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH MOST RECENT ONE FIRST) DATE MONTH

& YEAR

NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING FROM

TO

FROM

TO

FROM

TO

FROM

TO

OrlandHR\HR\Forms\Applications\Application for Employment Original 2008 Rev.5 – 5/4/2015 APPLICATION FOR EMPLOYMENT

REFERENCES (GIVE NAMES OF 3 PERSONS WHOM YOU ARE NOT RELATED) NAME BUSINESS PHONE NO YEARS KNOWN

AUTHORIZATION TO RELEASE INFORMATION

“I certify that the 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 authorized Pine Manor / Miller Poultry to contact the previous employers I listed on my job application to verify my employment with that company. I understand the information received by Pine Manor / Miller Poultry is private and will only be used for possible employment within the company. I understand this information will not be available for public inspection. I, the undersigned, authorize the release of any information concerning my employment records to be released to Pine Manor / Miller Poultry. This information is to be used for the possible employment with Pine Manor / Miller Poultry and will not be released for public inspection. I hereby release such person, agency, partnership or corporation from liability which may be incurred in releasing this information to Pine Manor / Miller Poultry including liability under any Federal Law. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.” SIGNATURE DATE

WITNESS FROM MILLER POULTRY DATE

OrlandHR\HR\Forms\Applications\Application for Employment Original 2008 Rev.5 – 5/4/2015 APPLICATION FOR EMPLOYMENT

OrlandHR\HR\Forms\Applications\Application for Employment Original 2008 Rev.5 – 5/4/2015 APPLICATION FOR EMPLOYMENT

REMARKS

NEATNESS CHARACTER

PERSONALITY ABILITY

HIRED FOR DEPT. POSITION WILL REPORT TO SALARY WAGES NEED THIS

PERSON SKILLS

SIGNATURE OF MANAGER AND/OR SUPERVISOR REVIEWED FOR DEPT YES NO

COMMENTS

APPROVED: 1. 2. 3.

EMPLOYMENT MANAGER DEPARTMENT HEAD GENERAL MANAGER ADP Date:

! V

! I

DO NOT WRITE BELOW THIS LINE

Office Use Only

Contact this candidate