PERSONAL INFORMATION

Name*

Home Phone*

Cell Phone*

Email Address*

Current address*

Due to the potentially hazardous nature of some of the job tasks at FELDMANS Farm & Home, we only hire ages 18 and above. Are you 18 years of age or older?*
YesNo

Are you a U.S. citizen or do you have the legal right to be employed in the U.S.?*
YesNo

Have you been convicted (or pleaded no contest to) any crime within the last 10 years (excluding minor traffic violations including driving under the influence of alcohol or drugs)?*
YesNo
NOTE: A conviction will not necessarily disqualify you from employment.

If Yes, state the offense, location, date, and disposition:

Do you have the ability, with or without reasonable accommodations, to work overtime or to travel if required by the job?*
YesNo

If No, please explain:

Drivers License:

State*

Type*

Currently Valid?*
YesNo

EMPLOYMENT DESIRED

Which type of employment are you seeking?*
Full Time EmploymentPart Time EmploymentTemporary or Summer Employment

At which FELDMANS location(s) are you interested in working?*
Liberty: 1332 W Kansas St, Liberty, MO 64068Blue Springs: 310 S 7 Highway, Blue Springs, MO 64014Bonner Springs: 430 N 130th St, Bonner Springs, KS 66012

Position applying for*

Desired salary or wage*

Date available to start*

Have you applied to our company before?*
YesNo

Have you ever worked for our company before?*
YesNo

If you answered Yes to either of the above questions, state when and where you applied and/or worked?

How did you learn of our company and/or the position?*

Are you now, or do you expect to be, working in any other business or job?*
YesNo

Are there any days or hours you would be unable or unwilling to work?*
YesNo

If Yes, please specify the days and hours you would be unable or unwilling to work.

EDUCATION

High School: Name and Address

Highest grade completed

Did you graduate?
YesNo

College or University: Name and Address

Number of years completed

Did you graduate?
YesNo

Degree

Major

Minor

Trade School: Name and Address

Number of months attended

Did you graduate?
YesNo

Diploma or certificate

If you did not graduate, why did you leave high school or college?

Are you planning to pursue further studies?*
YesNo

Is so, where an what courses?

Please describe any special courses, seminars, or training that could enable you to perform the position.

Have you served in the military?*
YesNo

Service Branch

Rank

CAPABILITIES/RELIABILITY

Are you able and willing to perform all the tasks required by the job for which you are applying?*
YesNo

If not, explain which tasks.

Have you filed any type of fraudulent claim against any of your present or past employers?*
YesNo

Will you abide by the safety rules of our company?*
YesNo

Have you ever been disciplined for violating company safety rules or regulations?*
YesNo

If Yes, please explain.

How many days of work (or school) have you missed in the last two years?*

How many times have you been late for work (or school) in the last two years?*

Consistent attendance and punctuality are essential requirements of every job in our company. Would you be willing and able to work on time every scheduled day on a regular and consistent basis?*
YesNo

If No, please explain.

Have you ever been disciplines or received a verbal or written warning for absenteeism or tardiness?*
YesNo

If Yes, please explain.

Have you ever been fired or asked to resign from a job?*
YesNo

If Yes, please explain.

WORK HISTORY
List names of employers in consecutive order with most recent employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, provide firm name and business references.

PLEASE DO NOT REFERENCE YOUR RESUME

Most Recent Job

Name of employer

Nature of business

Employer address

Phone number

Your title

Describe duties performed, skills used and learned, advancements, and promotions:

Dates employed
From
Month:
Year:

To
Current employer
YesNo

Month:
Year:

Starting salary or wage

Final salary or wage

Reason(s) for leaving

Second Most Recent Job

Name of employer

Nature of business

Employer address

Phone number

Your title

Describe duties performed, skills used and learned, advancements, and promotions:

Dates employed
From
Month:
Year:

To
Month:
Year:

Starting salary or wage

Final salary or wage

Reason(s) for leaving

Third Most Recent Job

Name of employer

Nature of business

Employer address

Phone number

Your title

Describe duties performed, skills used and learned, advancements, and promotions:

Dates employed
From
Month:
Year:

To
Month:
Year:

Starting salary or wage

Final salary or wage

Reason(s) for leaving

Fourth Most Recent Job

Name of employer

Nature of business

Employer address

Phone number

Your title

Describe duties performed, skills used and learned, advancements, and promotions:

Dates employed
From
Month:
Year:

To
Month:
Year:

Starting salary or wage

Final salary or wage

Reason(s) for leaving

SUPPLEMENTAL INFORMATION

If you worked in any of your previous positions under another name, please provide the name(s) below (for reference checking purposes)

Name

Company

Are you presently employed?*
YesNo

If yes, may we contact your current employer?
YesNo

What languages do you speak fluently?

SPECIAL SKILLS

Can you type?
YesNo

How many words per minute?

List all software programs in which you are proficient, indicating how many years of experience you have with each.

List other computer skills, programming languages, or computer training you have had.

List other technical training, skills, or work experience that you think qualify you for a position with us.

Use the space below to describe why you are interested in working for our company. List those skills and abilities that you feel particularly qualify you for a position with us.

REFERENCES

Please provide three references that are not relatives or former employers.

Reference 1

Name

Address

Phone Number

Occupation

Reference 2

Name

Address

Phone Number

Occupation

Reference 3

Name

Address

Phone Number

Occupation

ADDITIONAL DOCUMENTS

Include any documents here, such as a resume, cover letter, etc.

AFFIDAVIT
I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application or during any interviews may be grounds for my immediate discharge.

I hereby authorize FELDMANS Farm & Home to contact any company or individual it deems appropriate to investigate in my employment history, character, and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, the hereby waive my right ti bring any cause of action against these individuals for libel, slander, defamation, invasion of privacy, or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of FELDMANS Farm & Home. I understand that the taking of drugs and alcohol tests when given pursuant to company policy, are a condition of continued employment and refusal to take such a test when asked will be grounds for my immediate termination. I further understand that nobody in FELDMANS Farm & Home is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of FELDMANS Farm & Home. I also understand that my employment is at-will and may be terminated by myself or by the company at any time for any reason at all, with or without prior notice.

Name*

Date*

Fields marked with * are required.

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