PERSONAL INFORMATION                                            

NAME:                                                                       SOCIAL SECURTITY NO.

PRESENT ADDRESS:                                             CITY:              STATE:          ZIP CODE:

PREMANENT ADDRESS:                                      CITY:              STATE:          ZIP CODE:

PHONE NUMBER: (     )                                          REFERRED BY:

DATE OF BIRTH IF UNDER 18

Do you have the legal right to work in the U.S.?

  **Hire is subject to verification that applicant meets legal age and U.S. Work Permit requirements.

Have you, since the ago of 18 or within the last 7 years (whichever is most recent) been convicted of a felony?  If yes, describe briefly

 

 

 

EMPLOYMENT DESIRED

POSITION:                                        DATE YOU CAN START:               SALARY DESIRED:

ARE YOU EMPLOYED?                 IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

HAVE YOU EVER BEEN EMPLOYED BY CO-AG?                   WHERE?                   WHEN?

AVAILABLE FOR:   FULL TIME:             PART TIME:             TEMPORARY:         SUMMER:

I APPLIED AT COOPERATIVE AGRICULTURAL PRODUCERS, INC., AS A RESULT OF:

 

PLEASE LIST ANY HOURS OR DAYS YOU ARE RESTRICTED FROM WORKING:

 

HAVE YOU BEEN INFORMED OF, UNDERSTAND AND HAVE THE ABILITY TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB WITH OR WITHOUT ACCOMMODATION?          YES                 NO

 

EDUCATION

NAME AND LOCATION OF SCHOOL                                        YRS. ATTENDED              GRADUATED? (Y/N)    SUBJECTS STUDIED

GRAMMAR SCHOOL

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS OR

CORRESPONDENCE SCHOOL

 

GRAMMAR

SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING SKILLS:

 

 

U.S. MILITARY OR NAVAL SERVICE:                                       RANK:

PROFESSIONAL LICENSES AND AFFILIATIONS

DO YOU HAVE SPECIAL TRAINING?                TYPING COMPUTER         10-KEY         OTHER

 

 

 

FORMER EMPLOYERS

(LIST BELOW LAST FOUR EMPLYERS, STARTING WITH LAST ONE FIRST)

DATE (MONTH & YEAR)    NAME & ADDRESS OF EMPLOYER             SALARY      POSITION      REASON FOR LEAVING

FROM

TO

FROM

TO

FROM

TO

FROM

TO

 

REFERENCES

GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOW AT LEAST ONE YEAR

NAME OF BUSINESS OR INDIVIDUAL                       ADDRESS              OCCUPATION  PHONE        YRS KNOWN

1.

2.

3.

 

 

AUTHORIZATION

                “I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTANDING THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DIMISSAL.  I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.

                I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER IUNTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.”

 

 

SIGNATURE                                                                                     DATE:

                                   

INTERVIEWED BY:                                                                        DATE: