BERKOT's SUPER FOODS

Online Application

Applications need to be completely filled out to be considered.

Date: May 25,2013 @ 10:43 PM

Personal Information

Name
	first	last	middle	e-mail (not required)

List your addresses of residency for the past 3 years.

Current Address
	Street	City	State	Zip	How long? (yr./mo.)

	Phone Number

Previous Address(es)
	Street	City	State	Zip	How long? (yr./mo.)

	Street	City	State	Zip	How long? (yr./mo.)

	Street	City	State	Zip	How long? (yr./mo.)

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

"I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 291.23(d) and (e). I understand that I have a right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attachment to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

I also understand and agree to allow my application to be transmitted through the internet."

Employment Desired

Position(s) Applied for:

Start Date:

Rate of Pay Expected:

Are you currently employed?

If so, may we inquire of your present employer?

If not employed, how long since leaving last employment?

Ever applied at this company before?
Where?

When?

Rate of Pay?

Position?

Reason for leaving?

Referred By

Date of Birth (ex 05/11/1970)

Can you provide proof of age?

Have you ever been convicted of a felony? If yes, please state the type of conviction and the circumstances.

If yes, give dates and details:
Answering "yes" to this question does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be considered.

Are you authorized to work in the United States?

Is there any reason you might be unable to perform the functions of the job for which you have applied?

If yes, explain if you wish.

Have you ever been bonded? Answer only if a job requirement.

If so, name of bonding company:

Former Employers (List below last three employers, starting with last one first.)
All driver applicants to drive in intersate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate ot interstate commerce shall also provide and additional 7 years' information on thoes employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)

Check box if not applicable
Employer Name:	Address:	City:	State:
Employed From: To: (mm/dd/yyyy)	Contact Name: Contact Phone Number:	Your job position: Salary Paid:	Reason for leaving:
Were you subject to the FMCSRs while employed?	Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFS part 40?
Check box if not applicable
Employer Name:	Address:	City:	State:
Employed From: To: (mm/dd/yyyy)	Contact Name: Contact Phone Number:	Your job position: Salary Paid:	Reason for leaving:
Were you subject to the FMCSRs while employed?	Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFS part 40?
Check box if not applicable
Employer Name:	Address:	City:	State:
Employed From: To: (mm/dd/yyyy)	Contact Name: Contact Phone Number:	Your job position: Salary Paid:	Reason for leaving:
Were you subject to the FMCSRs while employed?	Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFS part 40?

submit
Berkot's Super Foods is an Equal Opportunity Employer.

This form is made available with the understanding that J. J. Keller & Associates, Inc.® is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc.® assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.