Valley Dairy - Employment
Valley Dairy Application For Employment! Valley Dairy Car Wash
(AN EQUAL OPPORTUNITY EMPLOYER)
Please answer all questions as completely as possible to ensure proper processing.
Date Position Applied for: Location preferred
Referred by: Advertisement Walk-In Current Employee Other
Personal Data:

Name:
First Middle Last Other or Maiden

Current Address:
Street Unit City State Zip Code

Permanent Address:
Street Unit City State Zip Code

Phone #: (ex. 701-555-1234)     Email:
Are you 18 years or older? Yes No
Are you legally eligible for employment in the United States? Yes No
Have you ever been employed by Valley Dairy or Valley Car Wash? Yes No
If yes, which location? Dates:
Availability:
How many hours per week would you like to work? Date available to start:

What times of the day would you be willing to work (check all that apply):
Morning (4:30am-12pm) Days (6am-6pm) Afternoon/Evenings (3-11pm) Overnights (11pm-7am)

Hours available to work:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Beginning:
Ending:
Education:
School - City & State # Years
Attended		 Did you
Graduate?		 Degree or Subject
Studied
High School Yes No
College/Vocational Yes No
In Case of Emergency Notify:
Name: Address: Phone #:
References: (Give the names of 2 people not related to you, whom you have know at least 1 year.)
Name Address Phone
(ex. 701-555-1234)		 Business Years
Acquainted
1.  
2.  
Other Information: (answering "yes" does not automatically disqualify candidate)
Have you ever been convicted of a misdemeanor or felony charge? Yes No
If yes, please explain giving dates and details
Employment Experience: (List all positions, starting with your present or most recent job. Include military service.)
Employer Employment Dates (mm/dd/yyyy) Job Title
From: to:
Address City State Phone (ex. 701-555-1234) Supervisor's Name
Duties and Responsibilities Wage/Salary
Start: $ Final: $
Reason for Leaving: Resigned with notice Resigned without notice Terminated Other
Please Explain
To the best of your knowledge, would this employer rehire you? Yes No
Employer Employment Dates (mm/dd/yyyy) Job Title
From: to:
Address City State Phone (ex. 701-555-1234) Supervisor's Name
Duties and Responsibilities Wage/Salary
Start: $ Final: $
Reason for Leaving: Resigned with notice Resigned without notice Terminated Other
Please Explain
To the best of your knowledge, would this employer rehire you? Yes No
Employer Employment Dates (mm/dd/yyyy) Job Title
From: to:
Address City State Phone (ex. 701-555-1234) Supervisor's Name
Duties and Responsibilities Wage/Salary
Start: $ Final: $
Reason for Leaving: Resigned with notice Resigned without notice Terminated Other
Please Explain
To the best of your knowledge, would this employer rehire you? Yes No

I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application, or if discovered after I am employed, may result in my dismissal.

I authorize VALDAK Corporation to conduct, at its discretion, felony convictions and motor record searches. I also authorize investigation of all statements contained in this application, to interview the references and previous employers listed in this application, and to obtain a report from a consumer reporting agency to be used for employment purposed in accordance with Fair Credit Reporting Act. I authorize the references and previous employers listed to give the Company all facts, opinions and evaluations concerning my previous employment and any other information they may have, reason for termination, character, salary history and other relevant determined by VALDAK Corporation. I release all such parties from any liability which may allegedly arise from furnishing such information to the Company, including, but not limited to, any liability for defamation or invasion of privacy.

If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug screen test. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, at the option of either the Company or myself. I understand that no manager, supervisor or other representative of the Company other than the President of the Company has any authority to enter into any agreement for employment for any specified period or time, or to make any agreement contrary to the foregoing.

I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by the Company to submit to drug screen test and that my failure to take such a test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am employed, may result in my dismissal.

I certify that I have read, understand and agree with the above.

Your Initials:

Date:

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