Application for Employment
Market Broiler

PLEASE PRINT

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the General Manager, District Manager or Corporate Office.

Location
Position(s) applied for        Date of application / /
Referral Source Advertisement Employment Relative Person
  Walk-in Private Employment Agency   Other

Name
  LAST FIRST MIDDLE

Address
  STREET CITY STATE ZIP CODE
Social Security #      

Telephone # ( ) Mobile/Beeper/Other Phone # ( )
E-mail Address    

If necessary, best time to call you at home is __________________________________________________________
: AM
PM
May we contact you at work? _____________________________________________________________________
Yes    No
If yes, work number and best time to call ______________________________________ ( )
: AM
PM
If you are under 18 and it is required, can you furnish a work permit? ______________________________________
Yes    No
If no, please explain
Have you submitted an application here before? _______________________________________________________
Yes    No
If yes, give date(s) and position(s)
/ /
/ /
Are you legally eligible for employment in this country? _______________________________________________
Yes    No
Date available for work / / What is your desired wage / salary range? $ per
Type of employment desired Full Time         Part Time         Temporary         Seasonal
Will you relocate if job requires it? ________________________________________________________________
Yes    No
Can you perform the functions of this job (essential and/or marginal), with/without reasonable accommodation?
Yes    No
Will you work overtime if required? _______________________________________________________________
Yes    No
If no, please explain
Have you ever pled “guilty” or “no contest” to, or been convicted of a crime? ______________________________
Yes    No
If yes, please provide date(s) and details
ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT

AN EQUAL OPPORTUNITY EMPLOYER
Employment History

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.
EMPLOYER
PHONE ( ) 		DATES EMPLOYED SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
FROM TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
 HOURLY RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND TITLE
$ PER
REASON FOR LEAVING
 HOURLY RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE?
YES NO LATER		 $ PER
EMPLOYER
PHONE ( ) 		DATES EMPLOYED SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
FROM TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
 HOURLY RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND TITLE
$ PER
REASON FOR LEAVING
 HOURLY RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE?
YES NO LATER		 $ PER
EMPLOYER
PHONE ( ) 		DATES EMPLOYED SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
FROM TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
 HOURLY RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND TITLE
$ PER
REASON FOR LEAVING
 HOURLY RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE?
YES NO LATER		 $ PER

EMPLOYER
PHONE ( ) 		DATES EMPLOYED SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
FROM TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
 HOURLY RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND TITLE
$ PER
REASON FOR LEAVING
 HOURLY RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE?
YES NO LATER		 $ PER

Educational Background

A. List the last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).
A. SCHOOL B. NUMBER OF YEARS COMPLETED C. DEGREE
DIPLOMA		 D. GPA
CLASS RANK 		E. MAJOR F. MINOR

Skills and Qualifications

Summarize any special training skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.



References

List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.

NAME TELEPHONE NUMBER OF YEARS KNOWN
( )
( )
( )

List any additional information you would like us to consider





Applicant Statement

I certify that all information provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from Market Broiler’s service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the end of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

It is my understanding that MARKET BROILER is an at-will employer and by understanding this it has been explained to me that if I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant ___________________________________________________ Date / /