Employment Application - Home Production Personnel

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

If required, are you willing to work overtime? *

Yes

No

Are you currently on "lay off" status and subject to recall with another employer? *

Yes

No

Are you legally eligible for employment in the United States? *

Note: all successful applicants will be required to provide proof of identity and eligibility for employment.

Yes

No

Have you applied for a position with Pleasant Valley in the past? *

Yes

No

Highest Level of Education *

High School

College

Technical School

Other

Did you graduate? *

Yes

No

Type of equipment you are able to operate *

Check all that apply

Computer

Calculator

Photo Copier

Fork Lift

Pallet Truck

Clamp Truck

Air Powered Nail/Staple Gun

May we contact for a reference? *

Yes

No

May we contact for a reference? *

Yes

No

May we contact for a reference? *

Yes

No

Please Read Carefully *

I understand that I will be required to submit to a urinalysis for the presence of drugs and/or alcohol as a condition of my employment. I also understand that if I am accepted for employment, I may be required to submit to further urinalysis for the same purposes and I agree to them on the same basis.

I Agree

Please Read Carefully *

I hereby certify that all questions are correctly answered and authorize the Company to contact my former employer, references and all other sources they deem necessary in order to verify facts and information furnish with regard to my character and qualifications. I also release the Company and its agents from all liability which might result from conducting this investigation. I further understand that the completion of this form and any addendum thereto does not assure me of a position with this Company or obligate the Company in any way, and that if hired, I may be terminated at any time at the Company's sole discretion. I further understand that any misleading or incorrect statements may render this application or any addendum thereto void, and if employed, may result in my immediate termination.

I Agree