Job Application Name (First, Middle, Last)*Preferred First NameToday's Date* Date Format: MM slash DD slash YYYY Email Address* Telephone*Alternative NumberAre you at least 18 years of age?*YesNoPresent Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent Address Street Address City State / Province / Region ZIP / Postal Code Position Desired*-- select a Job Posting --Agronomy Operations Manager - Region 5Agronomy Sales and Service Tech - Washta, IACustom Applicator - Hornick, IACustom Applicator - Pierson, IACustom Applicator - Rowan, IACustom Applicator - Ute, IAFuture Openings – Various LocationsLocation Manager - Bode, IAOutside Operations - Humboldt, IAOutside Operations - Pomeroy, IAOutside Operations - Seasonal Operations - Open LocationsPrecision Hardware Tech - Fort Dodge, IAShop Coordinator/Custom Applicator - Pomeroy, IATruck Driver - Bode, IATruck Driver - Pomeroy, IATruck Driver - Seasonal Tender Driver - Open LocationsTruck Driver - Ute, IAHave you applied at NEW Cooperative before?YesNoDate available to work* Date Format: MM slash DD slash YYYY Starting wage desired*Do you have the legal right to work in the United States?*YesNoHave you been subject to Federal Motor Carrier Safety Regulations*YesNoWill you relocate?*YesNoHave you previously worked at NEW Cooperative?*YesNoIndicate the type of employment desired* Full-time Part-time Temporary Fall Seasonal Spring Seasonal How did you find out about this position?*Have you ever been convicted of a crime other than a simple misdemeanor?*YesNoDo you have any physical or mental condition which would prevent you from performing any of the essential duties of the job for which you are applying?*YesNoIf yes, are you requesting that the company make any type of accommodation?EDUCATIONSelect highest year of school completed in each categoryHigh SchoolSelect Grade9101112College / UniversitySelect Years1234Graduate SchoolSelect Years12345High SchoolName of School (city, state)Major StudiesDid you graduate?YesNoCumulative GPA or grade AverageDegree / MajorBusiness, Trade or CorrespondenceName of School (city, state)Major StudiesDid you graduate?YesNoCumulative GPA or grade AverageDegree / MajorCollege (undergraduate)Name of School (city, state)Major StudiesDid you graduate?YesNoCumulative GPA or grade AverageDegree / MajorCollege (graduate)Name of School (city, state)Major StudiesDid you graduate?YesNoCumulative GPA or grade AverageDegree / MajorScholastic Honors, Scholarships, Assistantships, etc.CertificationsAttending school now?YesNoIf so, where?List subjects of special study or trainingForeign language proficiencyWORK HISTORYFull name of employerAddress City State / Province / Region Type of businessPositionName of supervisor/telephoneTypeFull-timePart-timeTemporaryFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Ending SalaryReason for LeavingDescribe major responsibilitiesPast Employer #2Full name of employerAddress City State / Province / Region Type of businessPositionName of supervisor/telephoneTypeFull-timePart-timeTemporaryFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Ending SalaryReason for LeavingDescribe major responsibilitiesBUSINESS / PROFESSIONAL REFERENCESReference #1NameTitleCompanyPhone NumberReference #2NameTitleCompanyPhone NumberReference #3NameTitleCompanyPhone NumberReference #4NameTitleCompanyPhone NumberRESUMEAttach your resume (.docx, .pdf, .odf)Please read carefully! “An applicant who is offered full or part time employment will be required as a condition of employment to participate and pass a drug screen to detect the use or presence of illegal substances as provided in company policy. I understand and agree that, if hired, my employment is at-will which means it is for an indefinite period of time and may be terminated by me or the company at any time with or without cause and without any advance notice regardless of the number of years of service with the company. I understand that this company has the right to investigate my driving record and past employment, education, and activities. I release from all liability all persons, companies and corporations supplying such information. I indemnify NEW Cooperative Inc. against any liability which might result from making such investigation. I understand that any false answer or statement or implications made by me in this application or other required documents may result in denial of employment or discharge.”Agreement* I agree Signature*Date* Date Format: MM slash DD slash YYYY Disclosure and Authorization For Release of Information As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, credit information reports, criminal history report and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are entitled to a copy of your Consumer Rights Under the Fair Credit Reporting Act. Authorization and Release To Obtain Information Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit NEW Cooperative, Inc. to obtain a consumer report and/or an investigative consumer report which may include the following: My employment records; Records concerning any driving, criminal history, credit history, civil record, worker’s compensation (post-offer only) and drug testing; (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years; Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records. I understand that an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I agree that a copy of this authorization has the same effect as an original. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as NEW Cooperative, Inc. from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification. I hereby authorize NEW Cooperative, Inc. to obtain and prepare an investigation consumer report as set forth above, as part of its investigation of my employment application. This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment. Agreement* I agree Signature*Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.