Please Type or Print

Date:

Name:

Address:

Telephone:

Social Security Number:

________________________________________________________________________

Position(s) You are Applying For:

Farm Market – Cashier, Driver, Stocker, Receiving

Agriculture – Greenhouse, Apple Orchard, Driver

Hours you are available for work (please state time and AM/PM)

From:

To:

________________________________________________________________________

Have you ever been convicted of a criminal offense?______ If yes, please state offense, date, place, and disposition of conviction:

Do you have any impairments, physical, mental, or medical, which would interfere with your ability to perform the job for which you have applied?_____If there are any positions for which you should not be considered, or job duties you cannot perform because of a physical, mental, or medical disability, please describe:

________________________________________________________________________

Were you in the military service?______ If yes, please describe:

________________________________________________________________________

High School

College

________________________________________________________________________

Other

________________________________________________________________________

_______________________________________________________________________________

Beginning with your present or most recent employer, please list the last three jobs you have held.

Name of Employer:

Type of Business:

Address:

Telephone:

Dates Employed: ________ to ________

Job Title:

Name of Immediate Supervisor:

Reason for Leaving:

Brief description of job responsibilities and experience:

May we contact this employer?

Name of Employer:

Type of Business:

Address:

Telephone:

Dates Employed: _________ to _________

Job Title:

Name of Immediate Supervisor:

Reason for Leaving:

Brief description of job responsibilities and experience:

May we contact this employer?

_______________________________________________________________________________

Name of Employer:

Type of Business:

Address:

Telephone:

Dates Employed: _________ to _________

Job Title:

Name of Immediate Supervisor:

Reason for Leaving:

Brief description of job responsibilities and experience:

May we contact this employer?

Please list three people, other than family members or former employers, as personal, business, or professional references.

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Please write in your own hand writing(not typed) for the following section.

Please briefly describe why you want to work for Lone Maple Farm and any further information which you feel would be of value to us in considering your application, such as skills, knowledge, experience, or other relevant qualifications. You may attach a resume if you so desire.

I authorize investigation of all statements contained in this application for employment. I understand that any misrepresentation or omission of facts called for herein will be sufficient cause for cancellation of consideration for employment or dismissal from the company's service if I am employed. I agree that Lone Maple Farm LLC and any of my previous employers shall not be held liable in any respect if any employment offer is not tendered, is withdrawn, or my employment is terminated due to falsity of the statements and answers in this application form. If I am employed, I will comply with all established policies, procedures, rules, regulations, job duties, responsibilities, and any revisions thereof, of Lone Maple Farm LLC. I hereby acknowledge that I have read and understand the above statements.

Applicant's Signature

__________________________________________________ Date: _______________________

State and Federal Laws prohibit discrimination because of race, color, religion, sex, national origin, age, disability, marital status, or arrest records unless based on a bona fide occupational qualification or other exception.

Return this completed form via mail to:

Lone Maple Farm LLC

2001 Hawleyton Road

Binghamton, NY 13903