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Employee Application Form |
This is "NOT" a secure form.
If you don't feel comfortable putting down certain information please
contact us.
ALL EMPLOYEES WILL BE SUBJECT TO RANDOM
DRUG TESTING
BEFORE AND DURING SEASON
First Name
Middle Name
Last Name
Address
City
State
Zip
Date which you can start work
/
/
Date which you can work until
/
/
CONTACT
INFORMATION
Home Phone #
School/Work
Cell
Phone #
Fax #
Email Address
Email Address 2
PERSONAL/MEDICAL INFORMATION
Date of Birth
/
/
Maritial Status
Do you wear corrective lenses?
Do you
smoke?
Do you have any
special dietary or medical problems that
may need special attention?
If yes, please explain blelow.
Note:
This question is optional and will be kept confidential.
Are you
on any medications?
If
yes, please list below:
Have you ever been arrested?
If yes, what were you convicted of?
PHYSICTIAN INFORMATION
Physician's Name
Address
Phone # of Clinic
EMERGENCY CONTACT
Name
Address
Relation
Phone Number of Contact
EDUCATION INFORMATION
High School Name
Did you graduate?
College/Major
DRIVER INFORMATION
(Please send a photo copy or a scan of
your drivers license to us for our records either by fax, mail, or email)
Drivers License Number
Expiration Date
/
/
State
Class of License
Endorsements
Restrictions
DOT Health
Card
Have you ever been charged with DWI or DUI?
Any violations or outstanding tickets in the past 5 years?
If yes, please list the violations below.
IF
YOU DON'T CURRENTLY POSSES A VALID COMMERCIAL DRIVERS LICENSE
WOULD
YOU BE WILLING AND ABLE TO OBTAIN ONE?
PREVIOUS EMPLOYER INFORMATION
Are you currently Employed?
Name of the Company?
Address
Phone Number
Supervisor
Dates of Employment
/
/
until
/
/
Work Description or Comments on this Employer
Name of the Company?
Address
Phone Number
Supervisor
Dates of Employment
/
/
until
/
/
Work Description or Comments on this Employer
Name of the Company?
Address
Phone Number
Supervisor
Dates of Employment
/
/
until
/
/
Work Description or Comments on this Employer
EXPERIENCE / SKILLS
Which position would you prefer?(choose as many as you prefer)
Truck Driver
Combine Operator
Graincart Operator
No Preference
Types of trucks and transmissions operated
Types of Combines Operated
Types of Tractors Operated
List of other related skills
Feel free to send us any additional information at mikeb@bbwi.net
or the fax listed on the bottom of the page.
All information on the document will be kept confidential.
You may also print the application out and mail it to Bergman Farms
1834 E Road Baileyville, KS 66404 or fax it to 785-336-6355.
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