Careers, Job Openings | Binghamton Agway

Application for Employment Form

We are a long-established local family company, operating on the principles of quality, service, and value. Join our team! Please submit your application online below. (*) indicate required fields to be filled for submission.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Location Applying For?*

Eureka LocationFerndale Location
Date Available to Start *

MonthDayYear
Date
Have you ever worked for this company?*

YesNo
If yes - when?
Please supply dates: from - to
Are you 18 years of age or older?*

YesNo
Are you a citizen of the U.S.?*

YesNo
If No - are you authorized to work in the U.S.?*

YesNo
Can you lift 50-lbs.?

YesNo
If No - how much can you lift?
Education
Please fill out the Education portion of this Form to the best of your ability.
High School Name
High School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended
From: - To:
High School Diploma?

YesNo
College Name
College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended
From: - To:
College Degree?

YesNo
Type of Degree
Other Education, Training, Certification...
Please briefly describe any other education, training, certificates, credits, degrees, etc.
Previous Employment
Please fill out this section starting with your last Employer to the best of your knowledge
Name of Previous - Employer 1
Company Name if Applicable
Address Employer 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Employer/Supervisor 1
Please enter a valid phone number.
Employment Dates - Employer 1
From: - To:
Position Held - Employer 1
Example: Clerk, Sales, Accounting, Warehouse, Ordering, Manager, Delivery, etc
Name Supervisor 1

First NameLast Name
Can we contact your previous Supervisor for a Reference?

YesNo
Reason for Leaving Employer 1
Name of Previous - Employer 2
Address Employer 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Employer/Supervisor 2
Please enter a valid phone number.
Employment Dates - Employer 2
From: - To:
Position Held - Employer 2
Example: Clerk, Sales, Accounting, Warehouse, Ordering, Manager, Delivery, etc
Name Supervisor 2

First NameLast Name
Can we contact your previous Supervisor for a Reference?

YesNo
Reason for Leaving Employer 2
Name of Previous - Employer 3
Company Name if Applicable
Address Employer 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Employer/Supervisor 3
Please enter a valid phone number.
Employment Dates - Employer 3
From: - To:
Position Held - Employer 3
Example: Clerk, Sales, Accounting, Warehouse, Ordering, Manager, Delivery, etc
Name Supervisor 3

First NameLast Name
Can we contact your previous Supervisor for a Reference?

YesNo
Reason for Leaving Employer 3
References
Please fill out this section with 3 professional references.
Reference 1*

First NameLast Name
Reference 1 Phone Number*

Area CodePhone Number
Reference 2*

First NameLast Name
Reference 2 Phone Number*

Area CodePhone Number
Reference 3*

First NameLast Name
Reference 3 Phone Number*

Area CodePhone Number
Military Service
Branch
Dates Served
From: - To:
Rank at Discharge
Type of Discharge
If other than Honorable, please explain
General
Subjects of special interest
Special Skills
Activities
Civic, Athletic, Specialized, etc.
Certification and Signature
I certify that the information on this application is true and correct to the best of my knowledge and I understand that any misrepresentation or omission of fact shall be cause for disqualification for employment or dismissal from employment. I hereby authorize an investigation of statements contained in the application and release from all liability and claims all persons and companies supplying information. I understand that my employment with the company would not be for any fixed period of time and that, if employed, I may resign at any time for any reason or the company my terminate my employment at any time for any reason.
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Application for Employment Form