I, _________________________, understand and agree that I am commencing
(print name)

employment whose continuation is conditional upon the results of my

pre-placement drug test being negative in accordance with North Farm

Cooperative’s Drug and Alcohol Policy. I understand and agree that a positive

test result will result in my immediate termination from employment with North

Farm Cooperative. I further understand that the consideration for my

agreement as set forth is being allowed to commence employment by North

Farm Cooperative prior to receipt of drug test results.

I understand that I must take the pre-placement drug test before beginning

work for North Farm.

Signed: ___________________________ Date: _____________________

Translator: ________________________ Date: _____________________

North Farm Cooperative
INTERVIEW QUESTIONS FOR WAREHOUSE WORKER

Please circle the correct response. If you answer no please explain.

Name_______________________________________ Date_______________
(print name)

Do you have the ability to lift 50 lbs. repetitively? Yes No

_________________________________________________________________

Do you have adequate transportation to and from work? Yes No

_________________________________________________________________

What has been your attendance history with your past employer?

Fair Good Very Good Excellent

Do you have any restrictions that may prevent you from doing your job? Yes No

_________________________________________________________________

_________________________________________________________________

Are you able to stand for long periods of time? Yes No

__________________________________________________________________

Have you operated any material handling equipment? Do you have a certification and or experience? (explanation not required for No responses)

Fork Lifts                            Yes                  No             certified                 experienced
Order Pickers                     Yes                  No           certified                 experienced
Reach Trucks                     Yes                  No             certified                 experienced
Electric Pallet Trucks        Yes                  No             certified                 experienced

Are you able and willing to work in cold, hot, dry and dusty environments? Yes No

_________________________________________________________________

Have you or are you willing to work in 35 degree environments 8 hours a day?

Yes No ________________________________________________________

Have you or are you willing to work in zero to 10 below environments 8 hours day?

Yes No ________________________________________________________

How would you rate your accuracy on a scale of 1 to 10?
1 being lowest and 10 being perfect accuracy ______________________________

How would you rate your safety record on a scale of 1 to 5?
1 being lowest and 5 being perfect safety _________________________________

Are you able to work at heights of 20 feet or more? Yes No

_________________________________________________________________

Are you able to work overtime through the week and on the weekends? Yes No

_________________________________________________________________

Do you have steel toe work shoes? Yes No

_________________________________________________________________

Circle the areas you have experience in:

Receiving Picking Shipping Packaging

Cycle Counting/Inventory Control Processing product returns

List any additional areas you have experience in and or provide explanation where necessary?
_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

When can you start? _____/_____/2001

What is your first choice for shift? First shift Second shift
(6:30a.m. to 2:30p.m.) (2:30p.m. to 10:30 p.m.)

What is your second choice for shift? First Second
(If not interested in 2^nd choice, don’t circle)

Can we check all employment and personal references? Yes No

List any past Employers that we cannot check.

_________________________________________________________________

_________________________________________________________________

As part of your qualification you will be instructed to make an appointment with Concentra Medical Center for a pre-employment physical, lifting capability exam, and drug and alcohol test. You are required to pass these tests.

I understand that false or misleading information given regarding these interview questions may result in discharge.

_________________________________ ________________________
Signature of Applicant Date