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Application For Employment – General
Please enable JavaScript in your browser to complete this form.
–
Step
1
of 6
Position Applying For
*
Personal Information
Name
*
First
Middle
Last
Phone
*
Email
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Are you 18 years of age or older?
*
Yes
No
List any other names that you have previously used to identify yourself, and identify the period of time that you used the name.
Are you legally eligible to work in the U.S.?
*
Yes
No
(If offered employment, eligibility documentation must be produced within 3 work days)
Have you previously been employed with Northern Country Cooperative?
*
Yes
No
If yes, you have been previously employed with NCC, please indicate dates, position held, department/location, and your reason for leaving.
How were you referred to us?
Type of Employment desired:
*
Full-Time
Part-Time
Temporary
Seasonal
Check all that apply.
Do you have any objection to working weekends and/or overtime if necessary?
*
Yes
No
Can you travel if required by this position?
*
Yes
No
Next
Education
Name of High School
Graduated High School?
Yes
No
Degree Earned
Diploma
GED
Name of College Attended (If Applicable)
Major Course of Study in College (If Applicable)
Number of Years
Graduated College? (If Applicable)
Yes
No
Degree Earned (If Applicable)
Associates
Bachelors
Other
Please list any other education opportunities pursued or graduate school, if any.
Next
Work Experience
List either your last four (4) places of employment or up to ten (10) years of employment history, starting with your present or most recent employer. Please respond to the following information completely. A resume may be included for additional reference.
Upload Resume
Click or drag a file to this area to upload.
Company Name #1 (Present or Former Employer – List most recent first.)
Dates of Employment (From M/Y to M/Y)
Job Title/Position
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason for Leaving (If not still currently employed there.)
Name of Supervisor
First
Last
Phone Number
May we contact for a reference?
Yes
No
If no, why not?
Job Duties/Responsibilities
Hours Per Week & Wage
Company Name #2
Dates of Employment (From M/Y to M/Y)
Job Title/Position
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason for Leaving
Name of Supervisor
First
Last
Phone Number
May we contact for a reference?
Yes
No
If no, why not?
Job Duties/Responsibilities
Hours Per Week & Wage
Company Name #3
Dates of Employment (From M/Y to M/Y)
Job Title/Position
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason for Leaving
Name of Supervisor
First
Last
Phone Number
May we contact for a reference?
Yes
No
If no, why not?
Job Duties/Responsibilities
Hours Per Week & Wage
Company Name #4
Dates of Employment (From M/Y to M/Y)
Job Title/Position
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason For Leaving
Name of Supervisor
First
Last
Phone Number
May we contact for a reference?
Yes
No
If no, why not?
Job Duties/Responsibilities
Hours Per Week & Wage
Next
Professional References
Provide the names of three references familiar with your current skills and abilities. Please do not include supervisors listed in the Work Experience section or family members.
Reference #1
First
Last
Company Name
Phone
Relationship & Years Known
Reference #2
First
Last
Company Name
Phone
Relationship & Years Known
Reference #3
First
Last
Company Name
Phone
Relationship & Years Known
Next
Driver's License Considerations
If the position you are applying for requires it, do you have a valid driver's license?
*
Yes
No
N/A
Do you have a Commercial Driver's License? (CDL)
*
Yes
No
If yes, list any CDL endorsements:
Have you ever had any license suspended or revoked?
*
Yes
No
If yes, state the type of license, the regulatory agency or body making the suspension/revocation, the date(s) of suspension/revocation, and the reason for the suspension/revocation:
Next
Closing Remarks & Submission
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions:
Applicant Signature
*
First
Last
Date
*
Northern Country Cooperative – An Equal Employment Opportunity Employer
This company does not unlawfully discriminate in hiring or any aspect of the employment relationship on the basis of age, race, color, sex, religion, national origin, disability, or any other basis protected by law in the jurisdiction in which the employment is performed.
Submit Application
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