Whittier Farms Inc.

Application for Employment

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All applicants will be considered for employment without regard to race, religion, color, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other status protected by law. We are an Equal Opportunity Employer.

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Date: ______/______/______

Name: ______Social Security No: ______

Address: ______Town: ______Zip Code: ______

Home Phone ( ) ______Cell Phone: ( ) ______

Do you have any physical limitations? ______

Are you under age 18? _____Yes _____ No

Are you eligible for employment in the United States? _____ Yes _____ No

Type of work preferred: _____ Full-Time _____ Part-Time

If Part Time, check days available: □ Mon ___ to ___ □ Tues ___to ___ □ Wed ___ to ___

□ Thurs ___to ___ □ Fri ___ to ___ □ Sat ___ to ___ □ Sun ___ to ___

Position or type of employment desired: ______

Salary or wages desired: $ ______□ Hr. □ Wk. Date available to start work: ____/_____/_____

Indicate special qualifications or skills: ______

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EDUCATION

High School / College/University / Other
School Name and Location
Years Completed (circle) / 9 10 11 12
Major Concentration

What classes of license do you posses? (Circle One) Class A B C D Issued by state: ______

List any Endorsement/Restrictions: ______

Do you currently have a medical card: _____ Yes _____ No (If hired, Whittier Farms will require an updated medical exam)

Have you ever been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court?

_____ No Record _____ Yes If yes, describe in full below

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EMPLOYMENT EXPERIENCE

Please give an accurate and complete full-time and part-time employment record.

May we contact your present employer? _____ Yes _____ No

START WITH YOUR MOST RECENT EMPLOYER

Employer: Phone:
( ) / From: / To:
Address: City, State, Zip / Position:
Duties: / Supervisor’s Name:
Starting Salary/Wages:
Reason for leaving: / Final Salary/Wages:
Employer: Phone:
( ) / From: / To:
Address: City, State, Zip / Position:
Duties: / Supervisor’s Name:
Starting Salary/Wages:
Reason for leaving: / Final Salary/Wages:
Employer: Phone:
( ) / From: / To:
Address: City, State, Zip / Position:
Duties: / Supervisor’s Name:
Starting Salary/Wages:
Reason for leaving: / Final Salary/Wages:

PERSONAL REFERENCES

Name / Address / Years Known / Telephone

APPLICANT’S AGREEMENT AND RELEASE

(Please read carefully before signing)

The above information is true and complete to the best of my knowledge. Should I be employed by Whittier Farms Inc., any misrepresentation or false statement contained herein may be considered cause for possible dismissal. Whittier Farms Inc. has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history or credit standing and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished by the Company.

I understand this application does not constitute an employment contract of any kind. Should I be employed by Whittier Farms Inc., I may resign such employment at any time at my discretion with or without prior notice and the Company may terminate my employment at any time at their discretion, with or without cause and with or without prior notice.

Date: _____/ _____/ _____ Signature of Applicant: ______