Position Applying For:

select... Route Delivery Driver Administration Receiving Outside Sales Rep Customer Service Management

How were you referred to us?

select... News Paper Ad School / Agency Work Force Commission Current Employee Other

Please Read Carefully

This Application form was designed for use by applicants for various positions. Answer the questions to the best

of your ability. All information will be treated confidentially. In completing this application all candidates agree

to resolve all disputes regarding this application for employment through the Company's Dispute Resolution

Program. The issuance of this application in no way constitutes an employment agreement. Bassham Foods is an

at-will employer and may hire, terminate with or without notice for cause or without cause. I hereby authorize

the company to verify all information on this application to include contacting my current or previous employer (s).

 Failure to complete this application in it's entirety may lead to rejection of the application by Bassham Foods.

If the information supplied by the applicant is found to be misleading, the company reserves the right to terminate

the application process or the employee should you be hired.

 I have read and I understand the above statement Select... Yes I understand No I do NOT understand

Employment History

All Applicants be advised that Bassham Foods verifies all listed employment history.

Please ensure all information is correct and employment history is complete.

Employer   

Dates of employment from        to

Address      

Phone number    

Supervisor's Name

Your Title     

Your Salary Starting       per   

Your Ending Salary        per

Please List your job duties. Be as specific as possible. 

Reason for leaving:   

Employer   

Dates of employment from     to

Address      

Phone number    

Supervisor's Name

Your Title     

Your Salary Starting       per   

Your Ending Salary       per

Please List your job duties. Be as specific as possible.

Reason for leaving:

Employer   

Dates of employment from     to

Address      

Phone number    

Supervisor's Name

Your Title     

Your Salary Starting       per   

Your Ending Salary       per

Please List your job duties. Be as specific as possible.

Reason for leaving:

Availability

How many hours would you like to work? select... Part Time Full Time Either Full or Part Time

What days are you available for work?

Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday

Are you available to work holidays? Yes  

What is your minimum weekly salary requirement? $

Date available to start work

Capability

Please check all that apply:     Basic Computer Skills      Microsoft Word    Microsoft Excel

Standup Forklift      Riding Electric Pallet Jack     Manual Pallet Jack     Certified  

Tractor Trailer     Bobtail    Reefer       

Languages  fluently spoken and read

English       Spanish       Other        

For Applicants Applying For Driving Positions ONLY

Do you have a commercial drivers license No  Class A  Class B  

Number of Tickets within the last three years

Number of Accidents within the last three years

Has your CDL ever been suspended or revoked? Yes  

If yes please list the date  

and the reason

Education

Please Check the highest level of education you have completed:

HighSchool / GED     Trade School   College     Other

Name

Number of years completed     Received Degree Yes   No

Degree/Major or Type of Course

Military Experience

Did you ever serve in the United States Armed Forces?  Yes   No

Dates of Duty To

Branch of Service

Rank at Separation

Honorably Discharged    Yes   No

Briefly describe your duties

General Information

Are you legally authorized to work in the United States? Yes    No

Are you below the age of 18?  Yes   

Do you know of any reason why you cannot perform the essential functions of the job for which you are

applying with or without reasonable accommodations?  Yes    No

Please Describe any accommodations required:

Have you ever been convicted of a criminal offense? True

Date    City

Nature

(An affirmative answer will not automatically disqualify you from being considered as a candidate for employment)

Are you currently awaiting a court trial or under indictment?True  

No question on this application is intended to secure information to be used for a discriminatory purpose,

as this company is an equal employment opportunity employer and does not discriminate on the basis of

race, color, religion, sex, citizenship, national origin, age, veteran, Reserve, National Guard, marital status,

disability, or any other legally protected status.

The following questions are optional

1. I have received a conditional certification from the state employment security agency (SESA) or a participating  agency

2. Please Check if any of the following apply to you.  

I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF)

for any 9 months during the last 18 months. I am a veteran and a member of a family that received food stamps

for at least a 3-month period with in the last 15 months. I was referred here by a rehabilitation agency approved

by the state or the Department of Veteran Affairs. I am at least age 18 but not age 25 or older and I am a member

if a family that:

                    A. Received food stamps for the last 6 months or

                    B. Received food stamps for at least 3 of the last 5 months, but is no longer eligible to receive them.

Within the past year I was convicted of a felony or released from prison for a felony and during the last 6 months

was a member of a low income family.

APPLICANT'S STATEMENT OF UNDERSTANDING AND AUTHORIZATION

I understand that this application will be given every consideration, but it's receipt does not imply that the

applicant will be employed. I understand that the company reserves the right to require a conditional offer of

employment medical examination a s well as periodic physical or medical examinations, a pre-employment as

well as a post employment drug and alcohol screening to be given by the company during employment.

I hereby state that the information given by me in this application is true in all respects, and I agree that if I am

employed and the information is found to be false in any respect that I may be dismissed for cause. Should I

be employed I understand that such employment will not result in an employment contract for any specific

term and that the company is an At-Will employer.

Applicant Signature

Date