APPLICATION FOR EMPLOYMENT
Stackhouse Grain LLC is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment
based on race, creed, color, age, religion, sex, national origin, marital status, arrest record or non-job related disability.
(Please print)
DATE OF APPLICATION__________________SOCIAL SECURITY NO._____________________
NAME: _____________________________________________________________________________
Last First Middle
PRESENT ADDRESS________________________________________________________________
Street City State Zip Code
DAYTIME PHONE ( )______________________HOME PHONE( )______________________
POSITION APPLYING FOR________________________EXPECTED SALARY_________________
HAVE YOU APPLIED TO THIS COMPANY BEFORE?________WHEN_______________________
WHO REFERRED YOU FOR THIS POSITION?___________________________________________
DO YOU HAVE A VALID DRIVERS LICENSE?__________TYPE_____________STATE_________
LICENSE NUMBER __________________________
DO YOU HAVE A GOOD DRIVING RECORD ___Yes___ __No ___ if no, explain_______________
LIST ANY RELATIVES WORKING FOR THIS COMPANY________________________________
ARE YOU LEGALLY ENTITLED TO WORK IN THE UNITED STATES? __Yes_______No_______
ARE YOU PHYSICALLY ABLE TO PERFORM THE FUNCTIONS OF THIS JOB?__Yes___No____
LIST ANY PREVIOUS INJURIES OR ILLNESSES THAT TOOK YOU AWAY FROM YOUR JOB AND HOW MUCH TIME WAS LOST____________________________________________________
EDUCATION
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High School Attended
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Years Completed 1 2 3 4 |
Graduate Yes No |
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College Attended
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Years Completed 1 2 3 4 |
Graduate Yes No |
Degree/Major |
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Trade/Business School
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Years Completed 1 2 3 4 |
Graduate Yes No |
Degree/Certification |
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HAVE YOU SERVED IN THE MILITARY? Yes_____No______WHICH BRANCH?______________
Date of Discharge__________Rank at Discharge____________Type of Discharge__________________
List any Experience/Skills you feel may be helpful to us in considering you________________________ __________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
REFERENCES (List three persons not related to you, whom you have known one year or more)
Name Address Occupation Years Known
1.__________________________________________________________________________________
2.__________________________________________________________________________________
3.__________________________________________________________________________________
List any outside activities in which you participate (civic, athletic, etc.) You may exclude any organization
whose name indicates race, religion, creed, national origin or disability of its members ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
List any special recognition of achievements you have received__________________________________
____________________________________________________________________________________
List employers in reverse order starting with the most recent.
EMPLOYER DATE
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Name
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From To Mo. Yr. Mo. Yr. |
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Address
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Position Held |
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City State Zip Code
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Contact Person Phone Number
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Reason for Leaving |
EMPLOYER DATE
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Name
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From To Mo. Yr. Mo. Yr. |
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Address
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Position Held |
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City State Zip Code
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Salary/Wage |
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Contact Person Phone Number
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Reason for Leaving |
EMPLOYER DATE
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Name
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From To Mo. Yr. Mo. Yr. |
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Address
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Position Held |
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City State Zip Code
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Salary/Wage |
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Contact Person Phone Number
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Reason for Leaving |
Are you currently employed?__________If so, may we contact your employer?____________________
Have you been convicted of a felony or a crime involving a fraudulent or dishonest act? Yes_____No___
If “Yes”, explain______________________________________________________________________
(Conviction of a crime is not an automatic bar to employment. Employment is conditional upon meeting the eligibility requirements for the Employee Fidelity bond.)
TO BE READ AND SIGNED BY APPLICANT
I certify that this application was completed by me and that all entries and information on it are true and complete to the best of my knowledge. I understand any misstatement of facts will subject me to non-hire and/or termination of employment. I understand that nothing contained in this application, the granting interview, or the distribution of manuals and handbooks will imply, create, or constitute a contract of employment. I understand that no supervisor or representative of this company, other than the __________________, has the authority to make any representation for employment for any specified period of time, or to make any representations contrary to the foregoing.
I understand that as an applicant, I will be asked to submit, and must pass, a pre-hire drug test; and that if I am offered employment, I may be subjected to drug screening during that employment. I understand if
I am offered employment; my employment may be subject to job-related medical screening examination. If I am granted employment, I agree to conform to the rules, regulations and policies of the Company. I understand my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at the option of Either the Company or Me.
I authorize the Company to make such investigations and inquiries of my personal history, employment history, medical history, credit history, or criminal history and any other related matters as may be necessary in arriving at an employment decision. I hereby do release employers, schools, health care providers and any other persons from any and all liability in responding to inquiries and releasing information in connection with this application. In the event of employment, I agree to and authorize the Company to withhold by Payroll Deduction, the payment of any past-due accounts which I may owe to the Company.
DATE_______________________SIGNATURE____________________________________________
