Careers, Job Openings | Binghamton Agway

Date*

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

Are you 18 years of age or older?*

YesNo

Are you legally eligible for employment in the U.S.?*

YesNo

Position(s) Applying For?*

What type?*

Full-timePart-time

Date Available to Start *

Date

Are you a student?*

YesNo

If you are a student or applying for part-time, please provide us with your availability.

Days You are Available for Work*

Hours You Are Available for Work*

MorningsAfternoonsEvenings

Have you ever been previously employed here?*

YesNo

If yes, list month and year*

MM/YYYY

Are you employed now?*

YesNo

If yes, may we contact your present employer*

YesNo

Education
Please fill out the Education portion of this Form to the best of your ability.

High School Name

High School Diploma?

YesNo

College Name

College Degree?

YesNo

Previous Employment
Please fill out this section starting with your previous Employer(s) to the best of your knowledge. Previous employers may be contacted unless you indicated otherwise.

Name of Previous - Employer 1

Address of Previous - Employer 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number of Previous - Employer 1

Please enter a valid phone number.

Email of Previous - Employer 1

example@example.com

Position Held or Title - Employer 1

Employment Dates - Employer 1

EX: From MM/YYYY to MM/YYYY

Job Duties of Previous - Employer 1

Name of Previous - Employer 2

Address of Previous - Employer 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number of Previous - Employer 2

Please enter a valid phone number.

Email of Previous - Employer 2

example@example.com

Position Held or Title - Employer 2

Employment Dates - Employer 2

EX: From MM/YYYY to MM/YYYY

Job Duties of Previous - Employer 2

References
Please fill out this section with 3 personal or professional references not related to you.

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

Please read the following carefully before signing this application
I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application of dismissal from subsequent employment.

I authorize any representative of Producers Cooperative Marketing Association bearing this release to obtain any and all information
from the references listed in this application relating to my activities or employment, including information that may otherwise be considered confidential. This information may include, but is not limited to, the circumstances under which I left my previous employment, my achievements, performance, experience, attendance, character, personal history, and disciplinary records. Using this authorization, I direct the references listed in this employment application to release such information upon request
by a representative of Producers Cooperative Marketing Association. I understand that the information released is for official use by
the Producers Cooperative Marketing Association and may be disclosed to such third parties as necessary, in the fulfillment of
official responsibilities.

I hereby release the references listed in this application, including their employers and any representatives of the reference or
employer, from any liability for damages that may result to me on account of compliance, or any attempts to comply, with this
authorization, including, but not limited to liability for demotion, libel, slander, or negligence.

I authorize the references listed on the previous to give you any and all information, including settlement agreements, nonrenewals, or termination, concerning my previous employment and any pertinent information they may have, personal or
otherwise, and release all such parties from liability for any damages that may result from furnishing the same to you.

“I UNDERSTAND AND AGREE THAT I WILL RECEIVE NO FURTHER REPLY UNLESS FAVORABLE CONSIDERATION IS GIVEN TO
MY APPLICATION.”

Signature*

Date*

Date

Liz's Pet Shop Employment Application

EMPLOYMENT DESIRED