Application for Employment Dean Brothers Inc. is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law. INTRODUCTORY INFORMATION: Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * APPLICANT QUESTIONS: Type of Work Desired Choose One Seasonal Part-Time Full-Time Desired Hourly Salary $ Date Available MM DD YYYY Confirm The Following Check all that apply. I can provide documents required to establish your eligibility to work in the U.S. I am 16 years of age or older. I have a valid driver's license. Have you ever been convicted of, or plead guilty or no contest to, a crime other than a minor traffic violation? * Choose one Yes No Explain how you were referred to Dean Brothers Inc. EDUCATION AND TRAINING High School or Last Grade Completed Provide Name & Address of School Course of Study Number of Years Completed Degree/Diploma College or Technical School Provide Name & Address of School Course of Study Number of Years Completed Degree/Diploma Other Schooling or Training Provide Name & Address of School Course of Study Number of Years Completed Degree/Diploma Military Experience Provide Branch of Service Time of Service Rank/Type of Service Job-Related Training/Experience EMPLOYMENT HISTORY Employer Name Supervisor Name First Name Last Name Employer Phone Number (###) ### #### Job Duties and Other Information Provide your Position Title Summary of Duties Salary upon Leaving Reason for Leaving Dates Employed Employer Name Supervisor Name First Name Last Name Employer Phone Number (###) ### #### Job Duties and Other Information Provide your Position Title Summary of Duties Salary upon Leaving Reason for Leaving Dates Employed WORK-RELATED REFERENCES Reference 1 Provide Name Occupation Years Known Contact Information Reference 2 Provide Name Occupation Years Known Contact Information Reference 3 Provide Name Occupation Years Known Contact Information Statement Agreement * I understand that employment with Dean Brothers is at-will, meaning that I or Dean Brothers may terminate my employment at any time, or for any reason consistent with applicable state or federal law. I authorize Dean Brothers to conduct a thorough background investigation of my work and personal history, and verify all data given on this application and during interviews. I hereby release Dean Brothers, and its representatives or agents, from any liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them from all liability for providing the requested information. I understand that Dean Brothers requires the successful completion of a drug and/or alcohol test as a condition of employment. I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire. I Agree I Do Not Agree OFFICE PERSONNEL USE ONLY ***DO NOT FILL OUT THIS SECTION*** ***INTERNAL USE ONLY*** Name of Interviewer and Date of Interview Start Date (if applicable) and Rate of Pay Division, Classification, and Benefits (540) 433-8873 | Email DeanBrothersInc.com 1358 North Main St. Harrisonburg, Virginia 22802 Dean Brothers Inc. has been providing excellence to the surrounding Shenandoah Valley region of Virginia and West Virginia since 1985.