Prospective Employment Questionnaire
— This information will be kept confidential.
Please note: We do not accept international applications at this time.
This form is for residents of the United States only. Thank you.
First Name:
Last Name:
Street Address:
City:
State:
AA
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
ON
OR
PA
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip:
Phone Number:
Fax:
(If available)
E-mail:
Highest Level of Education:
High School Graduate
Tech or Vocational School
2 Year College Degree
4 Year College Degree
Graduate Degree
Can you supply references from previous employers?
Yes
No
Were you ever in the Armed Services?
Yes
No
Are you legally authorized to work in the United States?
Yes
No
Can you lift and carry 50 pounds?
Yes
No
Area of interest:
Dairy
Swine
Beef
Livestock
Crops
Ag Business
Position desired:
Herdsperson
Assistant Herdsperson
Milker
General worker
Mechanic/Fieldwork
Service/Support
Fieldwork
Technical
Sales
Other (describe):
What State(s) are you interested in working?
Were you raised on a farm?
Yes
No
Your ability to supervise others is:
Above average
Average
No experience
Marital Status:
Married
Single
Breifly describe your prior employment. Please include positions held, location, length of employment, job duties and reason for leaving:
List any other job-related experiences, skills, licenses, certifications or qualifications you would like us to consider:
Please read this statement carefully before submitting this questionnaire.
I certify the answers given and statements made in this questionnaire are true and correct. I hereby release previous employers or references from liability or damages incurred as a result of inquiry or furnishing information concerning my personal character and employment skills.
THIS IS NOT AN OFFER OR GUARANTEE OF EMPLOYMENT.
I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THEM.
Phone: 608-221-3213
Toll Free: 1-800-551-9230
Fax: 608-221-3263
Email:
info@agri-man.com
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