Job Application

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 ORGIN, 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