Name
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First Name
Last Name
Email
*
Address
*
Please provide your Home Address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Please fill in the best number to reach you at.
(###)
###
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Position(s) Applying For
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Please fill in all positions you are applying for.
Referral Source-Name of Referral (if applicable)
Are you at least 18 years old?
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Have you ever filed an application with Heritage Farm, Inc. before?
*
If you responded YES to the previous question, please provide the date you previously applied.
Are you related to a Heritage Farm, Inc. employee?
*
If you responded YES to the previous question, please tell us who you are related to and what your relationship is.
Are you currently employed?
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If yes, may we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?
*
*Proof of citizenship or immigration status will be required upon employment.
On what date would you be available to start work?
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Type of employment desired?
*
Have you seen the job description of the position for which you are applying?
*
If yes, are you able to perform the functions of this position?
Have you ever been convicted of a criminal offense?
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*A criminal background check will be conducted when position is offered. Conviction will not necessarily disqualify applicant.
If yes, please explain. Please include the date of conviction.
Have you ever been excluded from participation in a federal or state healthcare program?
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If yes, please explain.
Education
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Please include the following: Name of School/Address of School/Years Completed/ Degree & Major (Did you graduate?)
Driving History-Do you have a New York State license?
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If other than NYS, where?
I.D. Class
*
I.D. Number
*
Date Issued
*
Expiration Date
*
Are you currently an unrestricted New York State driver?
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Will your driving history affect your ability to fulfill you job duties and responsibilities?
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Any conviction of DWI/DUI?
*
*A driving history will be obtained and monitored, and a copy of your driver's license and vehicle insurance (if applicable) will be required.
Professional References
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List TWO professional references that are NOT related to you.
Please provide their Name/Address/Phone Number/Years Known
Personal References
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List TWO personal references that are NOT related to you. Please include their Name/Address/Phone Number/Years Known
Qualifications-List professional trade, business, civic activities, and offices held
*
Please exclude memberships that would reveal sex, race, religion, national origin, ancestry, disability or other protected status.
Skills & Qualifications
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Summarize any special training, skills, licenses, and/or certificates (must show proof) that may qualify you as being able to perform job-related functions of the position for which you are applying.
Employment History (Job 1)-Employer Name
Employer Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer Phone Number
*
Job Title
*
Reason for Leaving
*
Summarize work performed and job responsibilities.
*
May we contact them?
*
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer Phone Number
Job Title
Reason for Leaving
Summarize work performed and job responsibilities.
May we contact them?
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer Phone Number
Job Title
Reason for Leaving
Summarize work performed and job responsibilities.
May we contact them?
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer Phone Number
Job Title
Reason for Leaving
Summarize work performed and job responsibilities.
May we contact them?
Comments
Include an explanation of any gaps in employment.
Applicant's Statement
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I certify that the answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed one (1) year. Any applicant wishing to be considered for employment beyond this should inquire whether or not applications are being accepted at that time.
I hereby acknowledge that any employment relationship with Heritage Farm, Inc. is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time, with or without cause.
In the event of employment, I understand that false, omission of, or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules, regulations, policies and procedures of the employer.
