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 disciplined 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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