Employment Application Step 1 of 4 25% Your Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone number*Cell phone numberEmail address* Date of Birth* MM DD YYYY Which position are you applying for?*Field workerDelivery DriverFarm Stand WorkerFarm Stand ManagerPack house/Greenhouse workerWhat date are you available to start?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you capable of lifting 50lbs or less?*Three characteristics that best describe you:*1. 2. 3. Why do you want to work at Deep Meadow Farm?*Please list any skills you have which might relate to agriculture?Additional information you would like us to know about your values, desires and work ethic:Are you taking any medication or have any medical conditions that could impact your safety or the safety of others while on the job?* Yes No If yes, please explain:Please check the box below acknowleging that you understand our drug policy.* I understand that Deep Meadow Farm is a DRUG FREE & TOBACCO-FREE FACILITY AND WORK PLACE. Driver's License & Driving InformationDo you have a valid driver's license?* Yes No What state was your driver's license issued from?*Has any license, permit or privelege ever been suspended or revoked?* Yes No If Yes, Why did your license or permit get revoked?Have you been involved in a traffic accident in the past 5 years?* Yes No Have you ever been convicted of a felony?*YesNoIf yes, what were you convicted of?Are you able to stand for 2-3 hours at a time?*This position may require that you are on your feet for extended periods of time. YesNoIf you are hired, what times of day can you work?* Employer 1 Information ( most recent employer)Employer 1 Name* Employer 1 - Address*Please fill in all information about your most recent employer. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer 1 - Phone Number*Employer 1 -How did you end your employment with this company?* I resigned I was terminated I am currently still employed here I am a seasonal employee Employer 1 - Job title*Employer 1 - Start date?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer 1 - End date?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer 1 - Contact Person?*Employer 1 - Contacts phone number?*Employer 1 - Do we have permission to contact this person as a reference?* Yes No Signature / Disclosure SectionPlease read and acknowledge at the bottom.*The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit and motor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer personality profile tests and verify my background. A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment and I agree to submit to a medical evaluation, if required. In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigative consumer report. In exchange for the consideration of my employment application by the company, I hereby release and forever discharge the company (including its directors, officers, employees and agents) and my past and/or present employers (their directors, officers, employees and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize persons to answer all questions asked concerning my ability, character, reputation and previous employment record. I understand that if my application is accepted that employment with this company at all times is employment "at will”. It is further understood that this “at will” relationship may not be changed by any written document, verbal statements, or by conduct unless such change is specifically acknowledged by an authorized executive of the company. I further understand that my “at will” employment may be terminated at any time by myself or the company and includes no guarantee, contract or promise of employment for any specific length of time. I understand that the first two weeks with Deep Meadow Farm is considered a trial period, and that my official start date will be after this period. In the third week of work with Deep Meadow Farm., I will have a review with the co-owners to determine any improvements to my performance deemed necessary, my rate of pay, and anything else the owners feel is pertinent to my success as an employee. I further understand that the first ninety (90) days of employment is a new hire introductory period. I understand and acknowledge that what I have submitted it true and complete. I agree and understand the terms of employment at Deep Meadow Farm Signature*I understand that by agreeing to the above terms and typing my name here that this is my digital signature. NumberUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledUntitledUntitledUntitledUntitledUntitledNameThis field is for validation purposes and should be left unchanged.