an Application.

4689 South 400 West, P.O. Box 480, Huntingburg, IN 47542
PHONE: (812) 683-4200 FAX: (812) 683-4226
Equal Opportunity Employer (EEO)
EMPLOYMENT APPLICATION
Applicant Information
Full Name:_______________________________________________________________________________Date:_______________
Last
First
Middle
Maiden
Street Address:____________________________________________City:___________________State:______ Zip Code:_________
Phone: _____________________________________
Social Security No:__________________________
Yes
No
Date of Birth ___________________
Are you 18 years or older?
*The employment age discrimination act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less
than 70 years of age.
Person to contact in case of an emergency: _________________________________________ Phone Number: _______________________
Date Available:__________________________Position Applied for:__________________________Desired Salary:$______________
Yes
No
Yes No
Will you work overtime and Saturdays?
Will you work regular hours?
Yes
No
Will you work any shift?
Yes
No
Are you authorized to work in the United States?
Yes No
Have you ever worked for this company?
If yes, when? ______________________________________________________
Yes No
*You will not be denied employment solely on the basis
Have you been convicted of a felony or misdemeanor within the last five (5) years?
of a conviction record, unless the offense is related to the job for which you have applied.
Education
High School/Location:____________________________________________________Years Attended:__________________________
____________________________________________________Year Graduated:_________________________
College/Trade/Location:___________________________________________________Years Attended:_________________________
___________________________________________________Year Graduated:_________________________
Military Background
Yes No
Have you ever been in the armed service?
Yes No
Presently in the National Guard?
Years of Service and Rank:___________________
Special Skills/Abilities
List any special skills you may have (I.E. welding, use of knives, typing, language, etc…)_____________________________________
____________________________________________________________________________________________________________
Previous Employment
1. Company:___________________________________Address:___________________________Phone:________________________
Job Title:___________________Supervisor:________________________Starting Salary:$___________ Ending Salary: $________
Responsibilities:_____________________________________________________________________________________________
From:____________________ to ________________________ Reason for leaving:_____________________________________
Yes No
May we contact your current/previous supervisor for a reference?
2. Company:___________________________________Address:___________________________Phone: _______________________
Job Title:___________________Supervisor:________________________Starting Salary:$___________ Ending Salary: $_______
Responsibilities:_____________________________________________________________________________________________
From:____________________ to ________________________ Reason for leaving:____________________________________
Yes No
May we contact your previous supervisor for a reference?
3. Company:___________________________________Address:___________________________Phone:_______________________
Job Title:___________________Supervisor:________________________Starting Salary:$_________ Ending Salary: $_________
Responsibilities:_____________________________________________________________________________________________
From:____________________ to ________________________ Reason for leaving:____________________________________
Yes No
May we contact your previous supervisor for a reference?
References
Please list three professional references.
1. Full Name:_____________________________________________________________Relationship:_________________________
Address:_______________________________________________________________Phone: _____________________________
2. Full Name:_____________________________________________________________Relationship:_________________________
Address:_______________________________________________________________Phone: _____________________________
3. Full Name:_____________________________________________________________Relationship:_________________________
Address:_______________________________________________________________Phone: _____________________________
Disclaimer and Signature
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified
statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may
result from furnishing same to you.
I understand that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated
at any time without prior notice.
Signature:_______________________________________________________________________ Date:________________________
Date Received in office_________________________
VERIFICATION OF SOCIAL SECURITY NUMBER
VERIFICACIÓN DEL NUMERO DE SEGURO SOCIAL
ALL APPLICANTS MUST COMPLETE THIS FORM.
Mi nombre es________________________________________________________________________________
(My Name is)
Nombre(First name)
Apellido(Last Name)
Segundo apellido(second)
Mi lugar de nacimiento es______________________________________________________________________
(My place of birth is)
Ciudad (City)
Estado(state)
Pais(country)
Mi fecha de nacimiento es______________________________________________________________________
(My birthday is)
Mes(Month)
Día(day)
Año(year)
El nombre de mi madre _______________________________________________________________________
(My mother’s maiden name) Nombre(First)
Apellido(Last name)
Segundo apellido(second)
El nombre de mi padre________________________________________________________________________
(My father’s name)
Nombre(First)
Apellido(Last name)
Segundo apellido(second)
El numero de mi seguro social es________________________________________________________________
(My social security number is)
Male / Hombre
Female / Mujer
Por favor verifíquelo a Farbest Foods, Inc. que mi numero de seguro social es el escrito arriba.
(Please verify to Farbest Foods, Inc. that my social security number is as shown above.)
________________________________________________________________
Firma (Signature)
___________________
Fecha (Date)
______________________________________________________________________________________________________________________
To be completed by a representative of the Social Security Office.
Information matches this social security number.
Information does not match this social security number.
_____________________________________________________________________
Representative’s Signature
____________________
Date
VOLUNTARY IDENTIFICATION QUESTIONAIRE
The purpose of this section is to assist in monitoring Affirmative Action Programs and to aid in complying with any
required Governmental record keeping or periodic reporting. This information is not part of your employment
application, and will not be considered in the employment/ selection process. If you choose to provide the information,
please complete the following:
Name: ___________________________________________________________________
Title of job applied for: ________________________________
Date: ____________________________
GENDER
____ Female
____ Male
ETHNICITY
Are you Hispanic or Latino origin? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin regardless of race.
___ Yes ___ No
RACE
If you answered No to the question above, please check the appropriate line below.
__ White
__ Asian (Far East, Southeast Asia or India subcontinent)
__ Black or African American
__ American Indian or Alaska Native
__ Native Hawaiian or Other Pacific Islander
__ Two or More of the above five (5) races