Dear Applicant,

Fletcher's Fine Foods, Ltd. prepares an affirmative Action Plan to help us comply with Federal/State Equal Employment Opportunity record keeping, reporting and other legal requirements. Please answer all questions below.

This Employment Information Form will be kept in a CONFIDENTIAL FILE separate from your personnel file and your application for employment.

All employees and job applicants are treated without regard to race, color, religion, sex, national origin, age, marital status, veteran status, medical condition, or handicap at Fletcher's Fine Foods, Ltd.

Name              Phone

Job Applying For         Date

Race/Ethnic Group                                White    Black    Hispanic
                                                            American Indian/Alaskan Native
                                                            Asian/Pacific Islander    Other

Sex                              Male                 Female

Are you a Vietnam Era Veteran?             Yes      No

Are you disabled or do you have a handicap?                Yes      No

Are you a disabled Veteran?                  Yes      No

If so, what is your disability rating?   

Fletcher’s Fine Foods, Ltd.
Employee Application

This Company does not discriminate in hiring or employment on the basis of race, religion, color, sex, national origin, ancestry, mental or physical handicap or disability, veteran or Vietnam era status. No question on this application is intended to secure such information to be used for such discrimination. This application will be given every consideration, but its receipt does not imply or guarantee that the applicant will be employed. This application will be kept on file for 90 days, after which, it will become inactive. You may reapply by submitting another application at a later date.

Last Name      First      Middle

Application Date

Present Street Address

City, State, Zip Code

Home Phone         Business Phone

Have you ever worked for us or applied for employment with us before?             Yes      No
If so, when?

Social Security #

Position Desired (application will be kept on file for 90 days)
1)     2)

Starting Salary Expected

Will anything prevent you from working full time?             Yes      No

Are you currently on layoff status or subject to recall?    Yes      No

Will you work overtime as needed?                                Yes      No

Are you over age 18?                                                    Yes      No

Do you have a right to work in the USA?                         Yes      No

Schedule Desired

How did you learn about us?      Employment Agency     Relative            Other

Have you been convicted of a felony in the last 5 years?      Yes      No
(An affirmative response will not automatically disqualify you from being a candidate for employment)
If so, please explain the circumstances

Are you able to perform the essential job functions for which you have applied with or without reasonable accommodation?                        Yes      No

Education

	Elementary School	High School	College/University	Graduate/Professional
School Name & Location
Years Completed
Diploma/Degree
Course of Study

References

Name and occupation (work references are preferred – no relatives)                     Address/Phone

1.

2.

3.

4.

 

Work History – Include Volunteer & Military Experience

Current Job

Employer	Manager	Phone #	May we contact? Yes         No
Address (Street, City, State, Zip)		Dates Employed  to	Starting & Ending Salary
Job Title		Hours / Week	Hours  Week Month  Annual
Job Duties			Date of Last Increase
			Incentive Earnings Yes  No
Reason for leaving or seeking change of position			Average Annual Earnings

First Previous Job

Employer	Manager	Phone #	May we contact? Yes         No
Address (Street, City, State, Zip)		Dates Employed  to	Starting & Ending Salary
Job Title		Hours / Week	Hours  Week Month  Annual
Job Duties			Date of Last Increase
			Incentive Earnings Yes  No
Reason for leaving or seeking change of position			Average Annual Earnings

Second Previous Job

Employer	Manager	Phone #	May we contact? Yes         No
Address (Street, City, State, Zip)		Dates Employed  to	Starting & Ending Salary
Job Title		Hours / Week	Hours  Week Month  Annual
Job Duties			Date of Last Increase
			Incentive Earnings Yes  No
Reason for leaving or seeking change of position			Average Annual Earnings

Third Previous Job

Employer	Manager	Phone #	May we contact? Yes         No
Address (Street, City, State, Zip)		Dates Employed  to	Starting & Ending Salary
Job Title		Hours / Week	Hours  Week Month  Annual
Job Duties			Date of Last Increase
			Incentive Earnings Yes  No
Reason for leaving or seeking change of position			Average Annual Earnings

Military

Branch                       Grade or Rank

Dates in service

Current Status              Other Information

Activities and Experience

List any professional, trade, business or civic activities and offices held, Also list achievements, or other special skills not mentioned elsewhere in this application that relate to the position(sl for which you are applying. You may exclude any references which would reveal race, religion, national origin, age, ancestry, disability or other protected status.

General Information

Please add any other information you feel is important for us th hear. For example, you may summarize your overall experience and relate it to your career goals. Use the back of this form if more space is required.

Emergency Contact

Name / Relationship

Please Read Carefully Before Submitting

I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand, that if employed misstatements or omissions of fact on this application shall be cause for dismissal after they have been discovered.

I understand that nothing contained in this employment application, the granting of an interview or any company policies, procedures or handbooks that I might receive are intended to create an employment contract between the Company and myself for either employment or the provision of any benefit. In the event of my employment with the Company, 1will comply with the rules and regulations as set forth in the Company handbook and other communications distributed to all employees. My employment, if hired, will be "at will" and can be terminated, With or without cause at any time at the option of either the Company or myself. This "at will" relationship may not be changed in writing or conduct unless by an authorized executive of the Company.

I authorize the Company to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends, and acquaintances. I understand that I have the right to make a written request within a reasonable period to receive additional detailed information about the nature and scope of such an investigation.

All rights, title, and interest, including, without limitation, all copyrights and patents, in and to any material produced or inventions developed by me which affect or relate to the Company's business or affect or relate to this Company's industry shall vest in the Company and I shall have no personal rights,  title or interest whatsoever herein.

I understand and acknowledge that employment may be conditional upon a favorable health evaluation which may include a physical examination to verify the ability to perform the essential job functions with or without accommodation and a chemical screening for Alcohol and/or Drugs in accordance with the Fletcher's Fine Foods, Ltd. Drug and Alcohol Policy. I understand I have the right to refuse to undergo such testing. However, the consequences of my refusal to undergo testing as an applicant will result in  the termination of the pre·employment selection process.

I also understand that future Drug and/or Alcohol screening may be required after my employment. I understand I have the right to refuse to undergo such testing. However, the consequences of refusal to undergo testing or a refusal to cooperate in testing as an employee will result in discharge for insubordination.

Former employers and educational institutions are authorized to give Company information about me. I hereby release them from all liability for releasing such information.

I authorize the Company to supply my employment record, in Whole or in part, and in confidence, to any prospective employer, government agency, or other party With a legal and proper interest.

The Company may also exercise its right to search Company property, including but not limited to desks, cabinets, lockers and other property when the situation warrants such inspection.

Any injury to me or death in connection with my employment shall be subject to worker's compensation laws. I waive for myself, my heirs and representatives, all actions at law against the Company for damages for such injury or death and agree to accept the applicable compensation award provided for by the laws of the state in which I am employed at the time of such injury or death.

I hereby acknowledge the I have read the above statements and understand what I have read.