(319) 988-3257  Tuesday, February 9, 2010
 
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East Central Iowa Cooperative Employment Application
East Central Iowa Cooperative considers applicants for all positions without regard to race, color, national origin, age, marital or veteran status, the presence of disability, or any other legally protected status. ECIC is an Equal Opportunity Employer.
Location   Department  
Personal Information
Last Name   First Name   Middle Name  
Driver's License (State)   Driver's License (Number)  
Current Address (Number & Street)  City   State   Zip Code  
Telephone Number(s)   Social Security Number  
Are you at least 18 years of age and can provide required proof of age after hiring? Y/N 
Have you ever worked for this company? Y/N 
If yes, give date and location: 
Reason for leaving:  
On what date would you be available for work? 
Name any relative working for ECIC: 
Can you travel if job requires it? Y/N 
Can you, at any time of employment, submit verification of your legal right to work in the United States? Y/N 
Have you ever been convicted of a crime, other than a minor traffic violation? Y/N 
Note: a conviction will not necessarily bar you from employment as each conviction will be assessed with respect to the time, circumstances, and seriousness as they relate to your employment. If yes, please explain.
Explanation:  
Position Applying for:  
Full Time   Part Time   Salary/Wage Desired  
Are you currently employed? Y/N 
If yes, may we contact your current employer? Y/N 
Explain:  
How did you learn about us? Advertisement   Employment Agency  
Friend   Relative   Walk-In  
Other  
Education
High School   Location  
Did you Graduate? Y/N  
College   Location  
Did you graduate? Y/N  
Major  
Trade/Business/Graduate School  Location  
Did you Graduate? Y/N  
Major  
Indicate equipment you can operate:
PC   Calculator   Typewriter  
Fax   PBX/Switchboard   Copy Machine  
Indicate programs you can work with:
Lotus   WordPerfect   Power Point  
Excel   Other  
Why are you interested in becoming an employee of ECIC?  
List any special job-related skills and qualifications acquired from employment or other experiences:  
Employment History-past ten years, list most recent first
Company Name   Supervisor  
Address   Telephone Number  
Responsibilities  
Dates of Employment: From:   To:  
Reason for leaving:  
Starting Wage $   Ending Wage $  
Company Name   Supervisor  
Address   Telephone Number  
Responsibilities  
Dates of Employment: From:   To:  
Reason for leaving:  
Starting Wage $   Ending Wage $  
Company Name  
Supervisor  
Address   Telephone Number  
Responsibilities  
Dates of Employment: From:   To:  
Reason for leaving:  
Starting Wage $   Ending Wage $  
Company Name   Supervisor  
Address   Telephone Number  
Responsibilities  
Dates of Employment: From:   To:  
Reason for leaving:  
Starting Wage $   Ending Wage $  
References:

Give name, address, and telephone number of three references who are not related to you and who are familiar with your abilities and work ethic.
Reference 1:  
Reference 2:  
Reference 3:  
Applicant's Statement:

I certify that the information provided by me on this Application Form is correct. I understand that the furnishing of any misleading information on this Application Form or its attachments will be just cause for termination should I become employed by East Central Iowa Cooperative, regardless of when or how discovered.

If hired for a position that requires driving a company owned vehicle, a rental vehicle or my personal vehicle for company business, I authorize East Central Iowa Cooperative to obtain a motor Vehicle report. East Central Iowa Cooperative's insurance company may also obtain a report through its sources. I understand that if the position I am applying for involves driving a motor vehicle, it is imperative that a good driving record exists.

It is agreed and understood that the company or its agents may investigate my background to ascertain any and all information of concerns to my employment history. I also authorize any and all of my former employers listed on this Application Form to furnish any information regarding my job performance. I agree to hold my former employers and their agents harmless from all liability that could relate in any way to disclosure of private information or an assessment  or opinion of my suitability for employment.

I understand that my employment is for no fixed term. I understand that employment with East Central Iowa Cooperative is on an at will basis and my employment may be terminated with or without notice by me or the Company. I also understand that no employee, officer or agent of the Company may bind it to anything contrary to the above by oral or printed statements, including handbook, benefit booklets or other forms of communication.
Initials of applicant:   Date:  
Administrative Use Only:
Schedule Interview: Y/N  
Remarks:  
Employed: Y/N  
Date of Employment   Job Title  
Hourly Rate/Salary $  
Notes:  
  

 
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