Employment Application Form

Employment Application Form

We understand that everyone has busy lives, so we have provided this form for your convenience when it suits your schedule.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you 18 years of age or older?*

YesNo
Position you are applying for...*
If the position involves heavy lifting, do you have any lifting limitations?*

YesNo
Have you had any previous injury or surgery to your back or neck?*

YesNo
Date available to start*

MonthDayYear
Date
Days you are available for work*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours you are available for work*

MorningsAfternoonsEvenings
Hours you are available for work*

MorningsAfternoonsEvenings
Hours requested per week*
Salary expectations*
Have you ever been previously employed by Agway?*

YesNo
If yes, when and where?
Have you ever been convicted of a felony?*

YesNo
If yes, please explain
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 Major
College Degree
Previous Employment

Please fill out this section starting with your last Employer to the best of your knowledge
Name of Employer 1
Position Held - Employer 1
Duties - Employer 1
Employment Dates - Employer 1

MonthDayYear
Date
Wages - Employer 1
Employer 1 - Supervisor Name

First NameLast Name
Employer 1 - Reasons for Leaving
Name of Employer 2
Position Held - Employer 2
Duties - Employer 2
Employment Dates - Employer 2

MonthDayYear
Date
Wages - Employer 2
Employer 2 - Supervisor Name

First NameLast Name
Employer 2 - Reasons for Leaving
Name of Employer 3
Position Held - Employer 3
Duties - Employer 3
Employment Dates - Employer 3

MonthDayYear
Date
Wages - Employer 3
Employer 3 - Supervisor Name

First NameLast Name
Employer 3 - Reasons for Leaving
References

Please fill out this section with 3 personal or professional references.
Reference 1 - Name

First NameLast Name
Reference 1 - Phone
Please enter a valid phone number.
Reference 1 - Years Known
Reference 2 - Name

First NameLast Name
Reference 2 - Phone
Please enter a valid phone number.
Reference 2 - Years Known
Reference 3 - Name

First NameLast Name
Reference 3 - Phone
Please enter a valid phone number.
Reference 3 - Years Known
Equal Opportunity Statement
Agway is committed to a Drug Free workplace. Applicants may be required to pass a drug screening test as a condition of employment. AGWAY IS AN EQUAL OPPORTUNITY EMPLOYER: Agway believes in providing equal opportunity for all and will not discriminate against any individual on the basis on race, color, religion, sec, national origin, age, disability or veteran’s status. All applications kept on file for 30 days.
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
Should be Empty:

Employment Application Form

Education

Previous Employment

References