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Application for Employment
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APPLICATION FOR EMPLOYMENT
Complete all required sections. Electronically sign and date, and then click “Submit”.
POSITION APPLYING FOR
Please select the position you are applying for from the list below:
--- Select ---
Cooler Warehouse
Plant-Machine Operator
Plant-Sanitation
Plant-Receiving
Maintenance-Facility
Maintenance-Operations
Yard Jockey
Office/Customer Service
Sales
PERSONAL INFORMATION
*First Name
Middle Name
*Last Name
*Phone
Phone Type
Home Phone
Cell Phone
*Email
*Street Address
*City
*State
*Zip Code
*Date of Birth
*Social Security Number
OTHER INFORMATION
*Have you ever been convicted of, or are you now under charges for, any misdemeanor or felony offense? Omit (1) traffic fines, (2) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law, (3) any conviction the record of which has been expunged under federal or state law, and (4) any conviction set aside under the Federal Youth Corrections Act or similar authority. (A yes response will not necessarily disqualify you from employment.
Yes
No
If checked yes, please explain.
If you have ever been granted a security clearance by any government agency, indicate the level of clearance, when granted, and by whom?
*Have you ever had a security clearance suspended, denied, or revoked?
Yes
No
*Are you bound by any non-solicitation / non-compete agreement?
Yes
No
*Have you ever interviewed for a job with Harrisburg Dairies, Inc.?
Yes
No
If yes, when?
*Have you ever been employed by Harrisburg Dairies, Inc?
Yes
No
If yes, when?
*Are any relatives or friends currently employed at Harrisburg Dairies, Inc.?
Yes
No
Name of employee(s) & Department where employed:
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SKILLS & QUALIFICATIONS
*Summarize specific skills and qualifications acquired from employment or other experiences that are related to the position for which you are applying (e.g., computer skills, software applications, foreign languages):
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EMPLOYMENT HISTORY
Please provide a COMPLETE employment history. List ALL employers, assignments, or volunteer activities that are relevant to the job for which you are applying, starting with the most recent, including military employment. Explain any gaps in employment in the "Comments" section below.
1 - Present/Most Recent Employer
*Present/Most Recent Employer
*Phone Number
*Dates Employed
*Address
*Immediate Supervisor/Title
*Job Title
*Type of Employment
Full Time
Part Time
Temporary
Other
*Reason for leaving or why you are considering leaving?
If currently employed, may we contact for reference?
Yes
No
*Starting Hourly Rate/Salary
*Final Hourly Rate/Salary
*Summarize the nature of the work performed and job responsibilities.
2 - Previous Employer
Next Previous Employer
Phone Number
Dates Employed
Address
Immediate Supervisor/Title
Job Title
Type of Employment
Full Time
Part Time
Temporary
Other
Reason for leaving or why you are considering leaving?
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Summarize the nature of the work performed and job responsibilities.
3 - Next Previous Employer
Next Previous Employer
Phone Number
Dates Employed
Address
Immediate Supervisor/Title
Job Title
Type of Employment
Full Time
Part Time
Temporary
Other
Reason for leaving or why you are considering leaving?
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Summarize the nature of the work performed and job responsibilities.
4 - Next Previous Employer
Next Previous Employer
Phone Number
Dates Employed
Address
Immediate Supervisor/Title
Job Title
Type of Employment
Full Time
Part Time
Temporary
Other
Reason for leaving or why you are considering leaving?
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Summarize the nature of the work performed and job responsibilities.
Comments
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REFERENCES
List three business / work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.
Reference 1
*Reference Name
*Reference Phone
*Years known
*In what capacity did this person observe you or your work?
Reference 2
*Reference Name
*Reference Phone
*Years known
*In what capacity did this person observe you or your work?
Reference 3
*Reference Name
*Reference Phone
*Years known
*In what capacity did this person observe you or your work?
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EDUCATION
Please complete the following education information.
High School
*Name and Location of School
Diploma or Degree (Credits Earned if No Degree)
Yes
No
*Attendance Dates
*Major
Business, Trade, or Technical*
Name and Location of School
Diploma or Degree (Credits Earned if No Degree)
Yes
No
Attendance Dates
Major
College*
Name and Location of School
Diploma or Degree (Credits Earned if No Degree)
Yes
No
Attendance Dates
Major
Graduate School*
Name and Location of School
Diploma or Degree (Credits Earned if No Degree)
Yes
No
Attendance Dates
Major
Other*
Name and Location of School
Diploma or Degree (Credits Earned if No Degree)
Yes
No
Attendance Dates
Major
*If degree was received under a name other than listed on this application, please provide your full name at the time the degree was awarded:
Degree
Name at Time Earned
Scholastic Acheivments
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REVIEW & SUBMIT
PLEASE REVIEW APPLICATION CAREFULLY. WE WILL NOT CONSIDER THIS APPLICATION IF NOT COMPLETED IN FULL.
PLEASE READ THE FOLLOWING AND SIGN THE APPLICATION IN THE SPACES PROVIDED BELOW. IF YOU HAVE ANY QUESTIONS, PLEASE SPEAK WITH THE HUMAN RESOURCES REPRESENTATIVE BEFORE SIGNING.
I understand that employment by Harrisburg Dairies is "at will". This means that the employment relationship can be ended by me or by Harrisburg Dairies at any time for any reason with or without advanced notice and with or without cause. It also means that Harrisburg Dairies may revise and make exceptions to its policies, practices, handbooks, manuals, rules, procedures, and regulations, in whole or in part, at any time. I further understand that no representative of Harrisburg Dairies, except the president, has any authority to enter into any agreement of employment for a definite term. Any such agreement must be in writing and signed by the president.
If employed by Harrisburg Dairies, I agree to comply with all safety and health rules, company policies and procedures, and local, state, and federal laws pertaining to my employment. Although management makes every effort to accommodate individual preferences, organizational needs may make the following conditions mandatory: overtime, rotating work schedule, or a work schedule other than Monday through Friday or normal business hours. I understand and accept these as conditions of my employment should I be hired.
I have reviewed this application carefully and I hereby affirm that my statements and answers to all questions on this application are true and correct and that I have not knowingly withheld any fact or circumstance that, if disclosed, would affect my application unfavorably. I understand that any misstatement or omission of fact on this application may result in my application not being considered, and if employed, may result in my immediate dismissal.
I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS:
*Signature of Applicant
*Today's Date
By signing below, I hereby authorize Harrisburg Dairies to conduct an investigative report and/or reference check concerning all statements contained in my application for employment; to interview all employers, references, and other individuals and institutions to obtain, including but not limited to, my education, employment history (except my current employer if I have so indicated), character, general reputation, driving record, credit history, and criminal record. In the event that I am employed by Harrisburg Dairies, I hereby authorize Harrisburg Dairies to answer any inquiries regarding my employment, conduct, qualifications, and reasons for leaving.
I understand that I have the right to request Harrisburg Dairies to disclose to me, completely and accurately, the nature and scope of the investigation. (Such a request must be made in writing to the human resources department within a reasonable time after you have completed and signed this authorization.)
In exchange for being considered for employment, I hereby release Harrisburg Dairies, its employees and agents, as well as any law enforcement agency, current or former employer, educational institution, credit agency, or any other individual providing information about me to Harrisburg Dairies, from any liability arising from disclosure of such information that is obtained during said investigation.
*Signature of Applicant
*Today's Date
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