Food Gatherers Application

Applicant Name______Date of Application______

(please print)

Street Address: ______

City: ______State:______Zip______Phone #______

TO BE READ AND SIGNED BY APPLICANT

I authorize Food Gatherers to make such investigations & inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I herby release employers, schools, heath care providers and other persons for all liability in responding to inquiries and releasing information in connections with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Food Gatherers.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;

Have errors in the information corrected by previous employers and for those pervious employers to re-send the corrected information to the prospective employer; and

Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Signature:______Date:______

FOR FOOD GATHERERS USE

PROCESS RECORD

PHONE INTERVIEW: YES______NO______

PHONE INTERVIEW CONDUCTED BY: ______DATE:______

All phone interview notes must be attached to the application after interview is conducted

IN PERSON INTERVIEW(S) CONDUCTED BY: ______DATE: ______

All interview notes must be attached to the application after the interview is conducted

APPLICANT HIRED: YES ______NO ______

DATE HIRED: ______START DATE:______STARTING RATE OF PAY: ______

HUMAN RESOURCES SIGNATURE: ______

DIRECT SUPERVISOR SIGNATURE: ______

TERMINATION OF EMPLOYMENT:

DATE TERMINATED: ______REASON TERMINATED: ______FINAL RATE OF PAY:______

LAST PAY CHECK DATE: ______

SUPERVISOR COMMENTS: ______

EILIGABLE FOR REHIRE? YES ______NO ______

SUPERVISOR SIGNATURE: ______DATE:______

POSITION APPLIED FOR: ______DATE: ______

NAME: ______SOCIAL SECURITY #: ______

Last First Middle

DATE OF BIRTH: ______

List your addresses of residency for the past 3 years:

Current Address: ______

Street address City/State/Zip How Long? Yr/mo.

Previous Address:______Street address City/State/Zip How Long? Yr/mo.

Are you eligible to work in the United States? YES ______NO______

Have you been convicted of or plead no contest to a felony? YES ______NO______

If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment – all circumstances will be considered

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)? YES ______NO______

If yes, explain if you wish: ______

EMPLOYMENT HISTORY

All driver applicants must provide the following information on all employers during the preceding 3 years. List complete mailing addresses, street number, city, state and zip code. NOTE: List employers in reverse order starting with the most recent. Add another sheet if necessary.

EMPLOYER NAME______FROM DATE:______TO DATE______

ADDRESS: ______CITY______STATE______ZIP______

CONTACT PERSON______PHONE #______

POSITION/TITLE:______

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES ______NO______

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES ______NO______

EMPLOYER NAME______FROM DATE:______TO DATE______

ADDRESS: ______CITY______STATE______ZIP______

CONTACT PERSON______PHONE #______

POSITION/TITLE:______

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED? YES ______NO______

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES ______NO______

EMPLOYER NAME______FROM DATE:______TO DATE______

ADDRESS: ______CITY______STATE______ZIP______

CONTACT PERSON______PHONE #______

POSITION/TITLE:______

Why did you leaving or why did you leave your previous job? ______

EXPERIENCE AND QUALIFICATIONS – OTHER

SHOW ANY EXPERIENCE THAT MAY HELP IN YOUR WORK FOR FOOD GATHERERS.

______

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION – INCLUDE COMPUTER EXPERIENCE/TRAINING

______

LIST SPECIAL EQUIPMENT OR TECHNICAL TRAINING MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

______

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED 1 2 3 4 5 6 7 8 HIGH SCHOOL 1 2 3 4

COLLEGE(S) ATTENDED ______CITY/STATE______

YEARS ATTENDED (FROM M/Y TO M/Y) ______DEGREE? ______(PLEASE LIST)

COLLEGE(S) ATTENDED ______CITY/STATE______

YEARS ATTENDED (FROM M/Y TO M/Y) ______DEGREE? ______(PLEASE LIST)

(USE AN ADDITIONAL SHEET OF PAPER IF NEEDED)

DRIVER POSITION INFORMATION – ONLY COMPLETE THIS SECTION IF YOU ARE APPLYING FOR DRIVER/FOOD RUNNER POSITION

Enter your License Information

Chauffer’s License? (please circle) YES NO Issuing State: ______Expiration Date: ______

CDL Class A (please circle) YES NO Issuing State: ______Expiration Date: ______

CDL Class B (please circle) YES NO Issuing State: ______Expiration Date: ______

Special Endorsements? (please list) ______

Has your license, permit or privileges to operate a motor vehicle been denied, revoked or suspended in the past 3 years? YES NO

If yes, please explain in detail what happened (use the back of this page if additional space is needed) ______

Experience:

Student Training? YES NO (if yes, list school) ______

Commercial Van YES NO

Reefer truck YES NO Type:______

Cube Truck YES NO Size:______

OTHER YES NO Explain ______

Background: Food Gatherers will run your driving record with the DMV please answer the following questions to the best of your ability. Food Gatherers only hires drivers with clean driving records.

In the last 3 years have you received a traffic citation? YES NO If yes, for what? ______

Please certify that following is true and complete list of traffic violations required to be listed (other than those I have provided under part 383) for which I have been convicted or forteited bond or collateral during the past 12 months:

If you have had no violations, check the following box: p NONE

DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

______

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Date of Certification ______Driver’s Signature______

Have you ever failed drug test? YES NO

Have you ever refused to take a drug test? YES NO

TO BE READ AND SIGNED BY APPLICANT

EQUAL EMPLOYMENT OPPORTUNITY POLICY

Food Gatherers is an equal opportunity employer. In accordance with state and federal law, we do not discriminate against applicants for employment or employees on the basis of race, physical or mental disability, color, creed, religion, sex, age, national origin, ancestry, citizenship, veteran status, sexual orientation, height, weight, or marital status. This policy of non-discrimination extends to all terms, conditions and privileges of employment and to all employment actions including hiring, promoting, compensation, benefits, training, demoting, layoffs, and discharge.

COMPLIANCE WITH DISABILITY LAW

Food Gatherers welcomes applications from people with disabilities and does not discriminate against them. Food Gatherers complies with all applicable provisions of the Federal American with Disabilities Act (1990) and the Michigan Handicappers Civil Rights Act (1977). Food Gatherers is committed to making reasonable accommodations for employees with disabilities who are otherwise qualified for their jobs.

Food Gatherers is an at-will employer. Thus, completion of this form does not guarantee employment and if hired, your employment is for no definite period of time and the employment relationship can be terminated by either you or Food Gatherers with or without notice, for any reason or for no reason. No supervisor or other Food Gatherers representative has the authority to alter this relationship or to change this policy, and you should never interpret the remarks of a supervisor or the Executive Director as a guarantee of employment.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature ______DATE______