*Position Applying For:

Date:

*First Name:

Middle Initial:

*Last Name:

Home Phone:

*Cell Phone:

Email:

*Are you under 18 years of age?:

Yes No

*I am a U.S. Citizen or otherwise authorized to work in the United States on an unrestricted basis:

Yes No

Business/Professional References

Name:

Address:

Phone:

Occupation:

Years known:

Name:

Address:

Phone:

Occupation:

Years known:

Name:

Address:

Phone:

Occupation:

Years known:

PAST EMPLOYER #1

Company Name:

Company City:

Company State/Province/Region:

Phone:

Supervisor Name:

OK to Contact:

Yes No

Employment Dates From:

Employment Dates To:

Job Title:

PAST EMPLOYER #2

Company Name:

Company City:

Company State/Province/Region:

Phone:

Supervisor Name:

OK to Contact:

Yes No

Employment Dates From:

Employment Dates To:

Job Title:

PAST EMPLOYER #3

Company Name:

Company City:

Company State/Province/Region:

Phone:

Supervisor Name:

OK to Contact:

Yes No

Employment Dates From:

Employment Dates To:

Job Title:

PAST EMPLOYER #4

Company Name:

Company City:

Company State/Province/Region:

Phone:

Supervisor Name:

OK to Contact:

Yes No

Employment Dates From:

Employment Dates To:

Job Title:

Name of School:

City, State:

Grade Completed:

Did you graduate?:

Yes No

Major:

Name of School:

City, State:

Grade Completed:

Did you graduate?:

Yes No

Major:

Name of School:

City, State:

Grade Completed:

Did you graduate?:

Yes No

Major:

Special honors or awards:

Position Information

Position Applying For:

Type of employment:

Full-time Part-time Seasonal/Internship

Preferred shift:

Days Evenings Weekends

Are you able to meet attendance requirements?:

Yes No

Are you willing to travel for the job?:

Yes No

Have you worked at Southeast Farmers previously?:

Yes No

When would you be available to start?:

Desired Salary:

How did you hear about this position:

Please describe any skills you have in the following areas:

Special honors or awards:

Other skills:

Driver and Mechanic Applicants Only:

Driving Record - List all licenses (Driver Applicants Only)

Enter State, License Type and Expiration Date for each license:

Do not include license number for security

Has license, permit or privilege to operate a motor vehicle ever been denied, revoked or suspended?:

Yes No

Enter the Date, City/State, Nature of the Accident/Violation, Preventable or Non-Preventable and the Number of Injuries/Fatalities:

Straight Truck:

Doubles:

Tractor-Trailer:

Other:

Indicate any safe driving awards you have received and from whom:

PLATFORM EXPERIENCE (DRIVER AND MECHANIC APPLICANTS)

Have you operated a forklift?:

Yes No

Years of forklift experience:

MECHANIC EXPERIENCE (MECHANIC APPLICANTS ONLY)

Are you ASE Certified?:

Yes No

You may attach your resume here if desired.

Please select a file

Accepted file types: pdf, doc, docx, Max. file size: 10 MB. I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history. Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.

I have applied for employment with Country Partners Cooperative and have provide information about my previous employment. By checking “I agree” below, I authorize my former or current employers and references to release the contents of my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Country Partners Cooperative, whether the information is positive or negative. I authorize Country Partners Cooperative to investigate all statements made in my application for employment and to obtain any and all information concerning my former / current employment. This includes my job performance appraisals / evaluations, wage history, disciplinary action(s) if any, and all other matters pertaining to my employment history. I knowingly and voluntarily release all former and current employers, references and Country Partners Cooperative from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Country Partners Cooperative. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign. This consent will be valid for no longer than six (6) months.

Employment Application

Contact Info

Address

Business/Professional References

Employment History

Education

Position Information

Driver and Mechanic Applicants Only: