Application Form Stickney Hill Dairy, Inc. is an Equal Opportunity Employer. Stickney Hill Dairy, Inc. does not discriminate on the basis or race, religion, color, sex, age, national origin or disability, or any basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization. Please print and fill out all sections Full Name Date Address City, State, Zip Phone Email Date Available Desired Salary $ Position Applied for Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES YES_2 NO Have you ever worked for this company? YES NO If yes when Are you applying for: Temporary work – such as summer or holiday work? Regular part-time work •Regular full-time work What days and hours are you available for work? If applying for temporary work, when will you be available? If hired, on what date can you start working? Can you work weekends? Can you work evenings? Are you available to work overtime? Additional Information Do you speak, write or understand any foreign languages? If yes, list languages(s) and how fluent of a speaker you consider yourself to be. Education High School Address From To YES NO Diploma College Address From To YES NO Degree Other From To YES NO Degree References Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Previous Employment Company Phone Address Supervisor Responsibilities From To Reason for Leaving YES NO May we contact your previous supervisor for a reference 1 May we contact your previous supervisor for a reference 2 Company Phone Address Supervisor Job Title Responsibilities_2 From To Reason for Leaving YES NO May we contact your previous supervisor for a reference 1_2 Company Phone Address Supervisor Job Title Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO Military Service Branch From To Rank at Discharge Type of Discharge If other than honorable explain Disclaimer and Signature Please Read Each Paragraph, then Accept Below I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material facts on this application or on any document used to secure employment can be grounds for rejection of application or, if I am employed by Stickney Hill Dairy, Inc., terms for my immediate expulsion from Stickney Hill Dairy, Inc. I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, by either me or Stickney Hill Dairy, Inc. I permit Stickney Hill Dairy, Inc. to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Stickney Hill Dairy, Inc. my former employers, and all others persons, corporations, partnerships and associations from an and all claims, demands or liabilities arising out of or in any way related to such examination or revelation. Δ
