APPLICATION FOR EMPLOYMENT
 
Send Application To: Dutch Farms, Inc.
700 E. 107th Street
Chicago, Illinois 60628 		Phone: 773-660-0900
Fax: 773-660-1044
Web: www.dutchfarms.com
NOTE:

  • You must be legally eligible for employment in the United States and be able to provide documents of eligibility.
  • A high school diploma or GED is required for employment.
  • Please answer all questions completely and accurately.  It is Dutch Farms policy is to verify information.
  
  • Qualified applicants will receive consideration regardless of race, age, sex, creed, national origin or disabilities.
  • Criminal convictions do not necessarily bar applicants from employment.
  • A pre-employment physical and drug test may be required.
PLEASE PRINT DATE: (02-05-2007)
PERSONAL INFORMATION
First Name:*

Middle Initial:
 Last Name:*

 SS#:
Present Address
Street:
City:
County:
State:
Zip:
Phone:* / Cell Phone: E-mail Address:*
If no phone, how can we contact you?
Are you at least 18 years of age?: Yes No Who referred you to Dutch Farms, Inc.?:
EMPLOYMENT DESIRED
For which position are you applying?: (office, warehouse, trucking, sales, etc.)
Date you can start: Desired Wage/Salary Range:
Preferred category: Full Time Part Time Either
Shift Desired: Dayshift Nightshift Either
Do you have any commitments that make it difficult for you to consistently work full shifts?:
Do you have any relatives or friends who work for Dutch Farms?: Yes No
EDUCATION HISTORY
  School Name
City, State: 		Course of
Study: 		Years
Completed: 		did you receive a diploma?:
High School (General) Yes No
College/Technical School Yes No
Current Enrollment Yes No
GENERAL
Have you been convicted of any crime in the last 5 years? Yes No   
If yes list the type, county, state and date:

Dutch Farms may verify via a criminal check.
Have you ever been warned/discharged by an employer for absenteeism, tardiness, failure to notify your
employer when absent, or any other attendance problem?  Yes No
Have you ever been warned about or discharged for sexual harassment, fighting, weapons, or related offense?
Yes No
Have you ever been warned or discharged by past employer for violating safety rules? Yes No
Please explain if you responded yes to any of the three previous questions:
EMPLOYMENT HISTORY: (Please include any military background within this section)
Most Recent Employer
Date:
 Name & Address of Employer: Wage/Salary:
 Position:
 Reason for Leaving:
From:

To:
 Employer Name:

Employer Address:
Start:

End:
 Start:

End:
Are you still employed there?: Yes No

May we contact them?: Yes No   Phone:

Supervisor/Contact: 		Work Performed:
Second Most Recent Employer
Date:
 Name & Address of Employer: Wage/Salary:
 Position:
 Reason for Leaving:
From:

To:
 Employer Name:

Employer Address:
Start:

End:
 Start:

End:
Are you still employed there?: Yes No

May we contact them?: Yes No   Phone:

Supervisor/Contact: 		Work Performed:
Other Recent Employer
Date:
 Name & Address of Employer: Wage/Salary:
 Position:
 Reason for Leaving:
From:

To:
 Employer Name:

Employer Address:
Start:

End:
 Start:

End:
Are you still employed there?: Yes No

May we contact them?: Yes No   Phone:

Supervisor/Contact: 		Work Performed:
CERTIFICATION AND RELEASE
I certify that the answers given by me to the above questions and the statements made by me are complete and true to the best of my knowledge.  I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment.  I authorize Dutch Farms, Inc. and/or its agents, including consumer reporting bureaus, to verify any of the information I have provided.  I authorize all former employees, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release and hold harmless said persons from any liability for any damage for issuing this information.  I also understand that the use of controlled substances is prohibited during employment.  I am willing to submit to drug/alcohol testing to detect the use of illegal drugs prior to and during employment.  I understand that this application or the acceptance of the same does not constitute an employment contract of any kind.  I further understand and agree that if employed, the employment will be “at will”.  That is, either Dutch Farms, Inc. or I may end the employment relationship at any time for any reason.
Applicants Name:

(In typing your name here you are agreeing to the information listed above.) 		Date:
FOR OFFICE USE
Interviewed by: Date:
Offered: Yes No
Accepted Offer: Yes No
Start Date:
Department: Rate: / Hour:


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