GENERAL INFORMATION
DATE: ___________________________
NAME: ______________________________________________________________________
DRIVER’S LICENSE #: __________________________________________________________
SOCIAL SECURITY NUMBER: ____________________________________________________
ADDRESS: ___________________________________________________________________
PHONE: ______________________________________________________________________
ARE YOU UNDER 18? YES_________ NO_________
IF ‘YES’ CAN YOU PROVIDE PROOF OF YOUR ELIGIBILITY TO WORK? YES_____ NO________
POSITION(S) APPLYING FOR: ____________________________________________________
HOW MANY HOURS CAN YOU WORK WEEKLY: _____________________________________
WHAT DAYS ARE YOU AVAILALE TO WORK:_________________________________________
WHEN ARE YOU AVAILABLE TO START WORK:_______________________________________
EMPLOYMENT HISTORY
CURRENT EMPLOYER: ___________________________________________________________
DATES EMPLOYED (MONTH/YEAR): FROM _________ TO __________
ADDRESS/PHONE: _____________________________________________________________
SUPERVISOR’S NAME: __________________________________________________________
REASON FOR LEAVING: ________________________________________________________
CURRENT PAY RATE: ____________________________________________________________
DESCRIBE WORK (JOB TITLE, SPECIFIC DUTIES, RESPONSIBILITIES, ETC.):
_________________________________________________________________________________________________
MAY WE CONTACT YOUR CURRENT EMPLOYER/SUPERVISOR? YES_____ NO_______
PAST EMPLOYER: _______________________________________________________________
DATES EMPLOYED (MONTH/YEAR): FROM _________ TO __________
ADDRESS/PHONE: _____________________________________________________________
SUPERVISOR’S NAME: __________________________________________________________
REASON FOR LEAVING: ________________________________________________________
PAY RATE:_____________________________________________________________________
DESCRIBE WORK (JOB TITLE, SPECIFIC DUTIES, RESPONSIBILITIES, ETC.):
_________________________________________________________________________________________________
EDUCATION & TRAINING
HIGH SCHOOL GRADUATE? YES___ NO ____
List other schools of training: name, location, dates attended, major(s), degree(s)
_________________________________________________________________________________________________
SPECIAL QUALIFICATIONS OR SKILLS THAT SHOULD BE CONSIDERED IN EVALUATING YOUR QUALIFICATION FOR EMPLOYMENT. PLEASE OMIT ANY INFORMATION THAT WOULD DISCLOSE YOUR RACE, GENDER, AGE, MARITAL STATUS, ETHNIC ORIGIN, RELIGIOUS OR POLITICAL AFFILIATIONS, OR DISABILITY:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
REFERENCES OTHER THAN RELATIVES (2-3): INCLUDE NAME, ADDRESS AND TELEPHONE:
_________________________________________________________________________________________________
Please attach a resume if available.
APPLICATION FORM WAIVER
PLEASE READ CAREFULLY
In exchange for the consideration of my job application by Dwyer Greens & Flowers, (hereinafter called “the Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plants, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment or to confer any rights to remain an employee by Dwyer Greens, or otherwise to change in any respect the employment-at-will relationship between it and the Owner/Managing Member of the Company. Both the undersigned and Dwyer Greens may end the employment relationship at any time, without specified notice or reason.
If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, all previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.
I understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relationship with the Company is terminable at will for any reason by either party.
AS INDICATION THAT YOU HAVE READ AND UNDERSTOOD EACH SENTENCE, PLEASE PRINT YOUR NAME AND SIGN IN THE SPACES PROVIDED BELOW
PRINTED NAME____________________________________________________
SIGNATURE OF APPLICANT___________________________________________
DATE_____________________________________________________________
Dwyer Greens & Flowers is an equal employment opportunity. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Dwyer Greens depends solely on your qualifications.
Thank you for completing this application
form and for your interest in our business.
4730 C.R. 335
P.O. Box 975
New Castle, CO 81647
Phone: 970-984-0967
Fax: (970) 984-0670
E-mail: lynndwyer@gmail.com