APPLICATION FOR EMPLOYMENT

Transcription

1 Bluestem Farm and Ranch Supply 2611 West Hwy 50 Emporia, Ks Store Hours: Mon-Fri 7am-8pm Sat 7am-5:30pm An Equal Opportunity Employer APPLICATION FOR EMPLOYMENT We consider applicants for all positions without regard to race, color, sex, age, religion, national origin, ancestry, disability, or any other legally protected status. Bluestem hires only persons lawfully authorized to work in the United States as required by law. Position Applied For: (Please Type or Print) of Application: Last Name First Name Middle Name or Initial Address City State Zip Code Telephone Number: Social Security Number: Available: Are you over the age of 18? Yes No Have you applied with this company before? When? Are you Available: Full Time Part Time Saturdays Education High School Undergraduate Graduate School Name and Location Years Completed Diploma/Degree Course of Study State and additional information you feel may be helpful to us in considering your application (such as any specialized training; skills; apprenticeships; honors received; professional, trade, business, or activities; job related military training or experience; foreign language abilities; etc.)

2 Employment History (Last Employer First) s Employers Name and Address Kind of Work Salary Reason for Leaving Additional Remarks If hired can you provide written proof of right to work in this country? Yes No Applicant s Statement I certify that the information given on this application is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application, and understand that false or misleading information given in my application or interview(s) may result in discharge. I understand and acknowledge that, unless otherwise defined by applicable law, and employment relationship with this organization is at will, which means that I may resign at any time and the employer may discharge me at any time with or without cause. I further understand that this at will employment relationship may not be changed orally, by any written document, or by conduct, unless such change is specifically acknowledged in writing by an authorized executive of the organization. Signature of Applicant

3 References: Please list three individuals who are not related to you by blood or marriage as references. Do Not Write Below This Line

4 Bluestem Farm & Ranch Supply, Inc W Hwy 50 Emporia, KS / / Fax Authorization to Obtain a Consumer Report Bluestem Farm and Ranch Supply, Inc. seeks permission to obtain a consumer report from a consumer reporting agency for employment purposes pursuant to the Federal Fair Credit Reporting Act of I,, authorize Bluestem Farm and Ranch Supply, Inc. to procure for employment purposes a consumer report from a consumer reporting agency. Applicant Signature Witness

5 Bluestem Farm and Ranch Supply, Inc W Hwy 50 Emporia, KS / / Fax Authorization for Drug Testing Bluestem Farm and Ranch Supply, Inc. hereby authorizes Newman Regional Health to administer drug testing on the individual identified as: Name Social Security Number Home Address Note: A photo driver s license is required for proper identification purposes. A Quest Reference Laboratory collection kit is required for each test as well as the Quest Reference Laboratory Chain of Custody form Collection will be submitted to Quest Diagnostics. PRISM Occupational Health, Wichita, Kansas will forward test results to Bluestem Farm and Ranch Supply, Inc. in care of Kenneth Bruner, President. Applicant Consent for Drug Tests I,, hereby give my consent and agree to give a specimen of my urine and submit to a drug test at Newman Regional Health in Emporia, Kansas. I understand that this specimen shall be used to detect the presence of alcohol, marijuana, and/or other drugs in my body. I further consent and agree that my pass (negative) or fail (positive) results shall be furnished to Bluestem Farm and Ranch Supply, Inc. in Emporia, Kansas by the testing facility. I understand that refusal to take this test, attempts to adulterate the specimen, or a positive test result for illegal drug use will result in Bluestem Farm and Ranch Supply, Inc. denying my application for employment. Further, I release all physicians, medical facilities, laboratory facilities, and Bluestem Farm and Ranch Supply, Inc. and its officers, employee representatives, designees and agents from any and all claims and liability for money or anything of value arising from the disclosure and use at evaluation in connection with my application for employment. Signature Witness Bluestem Farm and Ranch Supply, Inc.