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Employment Application

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Please complete all information below or click here to print a PDF application:

First Name*

Middle Name

Last Name*

Maiden

Present Address*

City*

State*

Zip*

How long at this address?

Home Phone*

Cell Phone*

Email*

If under 18, please list age

First date available to work?

Days/hours available to work – Please fill in times available on line by day of week or list “no preference” if you are available all days and any hours

Are you available to lift over 40#?*

Yes

No

Are you able to stand, lift, walk and bend for an extended period of time (6-8 hours)?*

Yes

No

Are you able to work outside in any type of weather elements (sun, rain, heat humidity, cold, etc.)*

Yes

No

Have you ever been convicted of a crime?*

No

Yes

If, Yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Do you have a driver’s license?*

Yes

No

What is your means of transportation to work?*

Reference #1 Name*

Reference #1 Phone*

How do you know Reference #1?*

Reference #2 Name*

Reference #2 Phone*

How do you know Reference #2?*

Name of Previous Employer

Previous Employer Phone #

Employment Dates: From – To

List duties performed, skills used or learned, and what you did on the job?

Name of Previous Employer

Previous Employer Phone #

Employment Dates: From – To

List duties performed, skills used or learned, and what you did on the job?

I certify that all of the information provided in this employment application is true and complete to the best of my knowledge. I understand that Stacy Family Farm may investigate information I have furnished. I authorize any person, firm or organization to supply any information about me concerning my past employment, convictions or any other information to Stacy Family Farm and I further release any such person, firm, or organization from any responsibility in disclosing such information, including from all liability for any damage that may result from furnishing such information to Stacy Family Farm.*

By Signing below, I certify that I have read and agree with these statements

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Stacy Family Farm is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on qualifications.

Join the Stacy Family Farm Team

27515 State Route 7
Marietta, OH 45750
(740) 374-2371

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