Grain Belt Supply Co., Inc.

Employment

Application For Employment - An Equal Opportunity Employer

Full Name

Email address

Phone

Current Address

City

State

Zip

Permanent Address

City

State

Zip

Please check if you are 18 Year or Older

Special Questions

Are you legally authorized to work in the U.S.?

What Foreign Languages do you speak fluently?

Read?

Write?

Have you been convicted of a felony or misdemeanor within the last 5 years?

Please describe:

**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

I understand and agree that I may be required to take one or more: Physical examination; Drug screen, as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such tests.

Employment Desired

Position applying for:

Starting Date:

Salary Desired:

Are you employed now?

If so, may we inquire with your present employer?

Have you ever applied to this company before?

Where:

When:

Education

Grammar School

Name and Location of School

*# of Years Attended

*Did you graduate?

Subjects Studied

High School

Name and Location of School

*# of Years Attended

*Did you graduate?

Subjects Studied

College

Name and Location of School

*# of Years Attended

*Did you graduate?

Subjects Studied

Trade, Business or Correspondence School

Name and Location of School

*# of Years Attended

*Did you graduate?

Subjects Studied

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

General

Subjects of Special Study or Research Work

U.S. Military or Naval Services

Rank

Present Membership in National Guard or Reserves

Former Employers

Please list below last three employers, starting with the most current first.

Name of Employer #1

Address of Employer

Phone Number

Salary

Position

Reason for leaving

Start Date

End Date

Name of Employer #2

Address of Employer

Phone Number

Salary

Position

Reason for leaving

Start Date

End Date

Name of Employer #3

Address of Employer

Phone Number

Salary

Position

Reason for leaving

Start Date

End Date

References

Give the names of three persons not related to you, whom you have know at least one year.

Reference Name #1

Address

Phone

Company

Years Acquainted

Reference Name #2

Address

Phone

Company

Years Acquainted

Reference Name #3

Address

Phone

Company

Years Acquainted

Can you perform the essential functions of your job, with or without a reasonable accommodation?

Please describe:

In case of emergency, please notify:

Name

Relation

Phone

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.

If hired, I understand that my employment is at-will and can be terminated at any time, with or without notice, for any reason at the option of the company or me. Should the company hire me, I agree to observe all the companys policies, practices and procedures currently in existence and new or revised ones, which may be issued in the future.

Date

Signature

Attach Resume