Farmhouse Creamery LLC	Pre-Employment Questionnaire

Equal Opportunity Employer	Date:

Personal Information

Name	Email address
Present Address	City/State/Zip Code	Date of Birth
Permanent Address	City/State/Zip Code
Phone	Cell Phone	Referred By:

Employment Desired

Position	Date You Can Start	Salary Desired
Are You Employed? Yes No	If yes, may we inquire of your present employer? Yes No
Ever applied to this company before? Yes No	Where?	When?

Education

Name and Location of School	Years Attended	Year of Graduation	Subjects Studied
High School
College
Trade, business or correspondence school
U.S. Military	Rank

Former Employers: List last three employers, starting with most recent

Date Month and Year	Name and Phone # of Employer	Salary	Position	Reason for Leaving
From:
To:
From:
To:
From:
To:

References: List the names of three persons not related to you, whom you have known at least one year.

Name	Telephone Number	Business	Years Known

For each shift, please place an “X” in the box to indicate if you are available to work.
Monday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Tuesday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Wednesday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Thursday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Friday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Saturday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No
Sunday	11:30am - 5:00pm	Yes No
5:00pm - 10:00pm (plus closing)	Yes No

How many hours are you looking for?

What makes you a good candidate for hire at Farmhouse Creamery LLC?

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."

Date: Signature: (type name)