Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the regulations prepared by the Bureau of Citizenship and Immigration Services. Proof of citizenship or immigration status will be required upon employment.

Full-Time Part-Time Seasonal

New Hampton Lawler Ionia North Washington Nashua Burchinal Rockwell Dougherty Klemme Mason City Ventura Hanlontown Joice Scarville

Yes No

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness of nature of the violation, rehabilitation and position applied for will be taken into account.

Yes No

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Employment Background

EMPLOYER 1

Yes No

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EMPLOYER 2

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Moving Violations From The Past Three Years

Violation #1

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Documents

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge, The Company may investigate all statements contained in this application, and I understand that any false or misleading information provided may result in my immediate discharge if I am hired. Similarly, any false or misleading information provided in post-offer questionnaires or medical examinations will result in discharge regardless when discovered. I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND THE COMPANY IS TERMINABLE-AT-WILL SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING. I also understand that any offer of employment may be conditioned upon health evaluation by a doctor selected by the Company to determine whether I qualify for the position being considered. In addition, I understand a drug or alcohol test is required. I authorize the Company to make a thorough investigation of my past employment, education, and job-related activities, and I release from all liability all persons, companies, and corporations supplying such information. I also indemnify this Company against any liability that might result from making such investigation. Additionally, I authorize the Company to supply by employment record, in its sole discretion, in whole or in part, to any prospective employer, government agency, or other party with an interest that the Company deems appropriate.