We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
PLEASE PRINT:     Position(s) Applied For                                                            Date of Application
How Did You Learn About Us?
r Advertisement
r Employment Agency		 r Relative
r Friend		 r Inquiry
r Other _______________________________

____________________________________________________________________________________________________________________________
Last Name                                                                       First Name                                                Middle Name

____________________________________________________________________________________________________________________________
Address                 Number                          Street                                                      City                                 State                  Zip Code

____________________________________________________________________________________________________________________________
Telephone Number(s)                                                                                                                              Social Security Number (voluntary)
Best time to contact you at home is: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .___:_____ AM or PM
If you are under 18 years of age, can you provide required
proof of your eligibility to work?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		 r Yes   r No
Have you ever filed an application with us before?  . . . . . . . . . . . . . . . . .  . . . .
         If Yes, give date ______________		 r Yes   r No
Have you ever been employed with us before?  . . . . . . . . . . . . . . . . . . . .  . . . . 
         If Yes, give date ______________		 r Yes   r No
Do any of your friends or relatives, other than spouse, work here? . . . . . . . .  . . . . r Yes   r No
Are you currently employed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . r Yes   r No
May we contact your present employer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes   r No
Are you prevented from lawfully becoming employed in this
country because of Visa or Immigration Status
Proof of citizenship or immigration status will be required upon employment. 		 r Yes   r No
Date available for work ___/___/___     What is your desired salary range? ______________

Are you available to work?  r  Full-Time    (please indicate   1     2     shift)
                                           r  Part-Time    (please indicate  Mornings   Afternoons   Evenings)
                                           r  Temporary  (please indicate dates available __/__/__ - __/__/__)
Are you currently on "lay-off" status and subject to recall? . . . . . . . . . . . . . . . . . . r Yes   r No
Can you travel if a job requires it? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  r Yes   r No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

 

  Name and Address
of School		 Course of Study No. of Years
Completed		 Diploma
Degree
Elementary
School		        
High
School		        
Undergraduate
College		        
Graduate
Professional		        
Other
(Specify)		        
Describe any specialized training, apprenticeship, and skills.

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

 

Start with your present or last job.  Include any job-related military service assignments and volunteer activities.  You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
1. Employer
Dates Employed
From To
   
Hourly Rate/Salary
Starting Final
   

Worked Performed
Address
Telephone Number(s)
Job Title            Supervisor
Reason for Leaving
2. Employer
Dates Employed
From To
   
Hourly Rate/Salary
Starting Final
   

Worked Performed
Address
Telephone Number(s)
Job Title            Supervisor
Reason for Leaving
3. Employer
Dates Employed
From To
Hourly Rate/Salary
Starting Final

Worked Performed
Address
Telephone Number(s)
Job Title            Supervisor
Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.
List professional, trade, business or civic activities and office held.  You may exclude membership which would reveal gender, sexual orientation, race, religion, national origin, age, ancestry, disability or other protected status:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
_________________________________________________________________________________

 

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
SPECIALIZED SKILLS (CHECK SKILLS/EQUIPMENT OPERATED)
 ___ Terminal
 ___ PC/MAC
 ___ Typewriter
        WPM ___		  ___ Spreadsheet
 ___ Word Processing
 ___ Shorthand
        WPM ___		 Machinery
 ___  Forklift
 ___ Order Picker
 ___ Reach Trucks
 ___ Electric Pallet Trucks		 Other Mobile        Machines
_______________
_______________
_______________
State any additional information you feel may be helpful to us in considering your application.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Note to Applicants:  DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?  A review of the activities involved in such a job or occupation has been given.
  ____ YES   ____ NO
REFERENCES
1.                                                                                          (           )                                           
                                   (Name)                                                                                          Phone #
                                                                                                                                                     
                                    (Address)
2.                                                                                         (           )                                            
                                   (Name)                                                                                            Phone #
                                                                                                                                                     
                                    (Address)
3.                                                                                          (           )                                           
                                   (Name)                                                                                            Phone #
                                                                                                                                                     
                                    (Address)                                                                                    

 


I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.  It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.





        ____________________________________                    _________________________
                       Signature of Applicant                                                                 Date 

 

 

 

FOR PERSONNEL DEPARTMENT USE ONLY

 Position(s) Applied For Is Open:   r Yes   r No

  Position(s) Considered For:__________________________________________

                                           ___________________________________________

                                            Date ______________________________

 

  Arrange Interview     r Yes     r No
  
  Remarks
   _____________________________________________________________________
  
   _________________________________________  ___________________________ 
                               INTERVIEWER                                                                          DATE 
   
    Employed     r Yes   r No                Date of Employment________________________
  
    Job Title _____________________________________________________________ 

    Hourly Rate/Salary _______ Department ____________________________________
                    
    By _________________________________________________________________
                                              NAME AND TITLE                                                          DATE

 
Please send application to: North Farm Cooperative
Attn: Lisa Weatherwax
204 Regas Road
Madison, WI  53704




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