Employment - Farm & Home Supply

Application for Employment

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Deparment.

Position(s) applying for

Name: Last	First	Middle

Social Security Number - -

Address: Street	City	State	Zip Code

Contacts: Phone #	Mobile/Beeper/Other #	E-mail Address

Referral Source (How did you hear about us?)

If you are under 18, and it is required, can you furnish a work permit?	Yes No
If no, please explain
Have you ever been employed here before?	Yes No
If yes, give dates and positions
Are you legally eligible for employment in this country?	Yes No
Date available for work
What is your desired salary range?
Type of employment desired
Full-Time Part-Time Temporary Seasonal Educational Co-op

Most Recent Employment

Employer	Telephone #

Street Address	City	State

Starting job title	Starting Compensation
	$ per hourly salaried
Start Date (mo/year)	Commission/Bonus/Other Compensation
	$
Final job title	Ending Compensation
	$ per hourly salaried
End Date (mo/year)	Commission/Bonus/Other Compensation
	$
Immediate supervisor and title (for most recent position held)

May we contact for a reference? Yes No Later
Why did you leave?

Summarize the type of work performed and job responsibilities

Prior Employment

Employer	Telephone #

Street Address	City	State

Starting job title	Starting Compensation
	$ per hourly salaried
Start Date (mo/year)	Commission/Bonus/Other Compensation
	$
Final job title	Ending Compensation
	$ per hourly salaried
End Date (mo/year)	Commission/Bonus/Other Compensation
	$
Immediate supervisor and title (for most recent position held)

May we contact for a reference? Yes No Later
Why did you leave?

Summarize the type of work performed and job responsibilities

Education

Begin with the most recent school you attended.

School Name & Address

Years	Major/Minor	GPA/Class Rank

Completed
Diploma GED Degree Certification Other

School Name & Address (#2)

Years	Major/Minor	GPA/Class Rank

Completed
Diploma GED Degree Certification Other

School Name & Address (#3)

Years	Major/Minor	GPA/Class Rank

Completed
Diploma GED Degree Certification Other

References

List names and phone numbers of 3 business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list 3 school or personal references who are NOT related to you.

Reference #1

Name
Title
Relationship to You
Phone
Years Known

Reference #2

Name
Title
Relationship to You
Phone
Years Known

Reference #3

Name
Title
Relationship to You
Phone
Years Known