Step 1 of 6: Delivery Driver, Shuttle Driver Employment Application

Please fill out this form in its entirety.

* First Name	* Last Name	Middle	Date
Present Address
* Street Address	* City	* State/Province	* Postal Code
* Phone		Email
Permanent Address
Street Address	City	State/Province	Postal Code
* Are you 19 years or older? Yes No		* Are you 16 years or older? Yes No
Education
* Are you still a student?	Where	Major/Area of Study	Expected Graduation Date
* Are you a college graduate?	Where
* High school graduate?	Where

Step 2 of 6: Driving, Background History

Driving Information
Driver's License #		License State
Driver's Expiration		Have you been convicted of a DUI within the last five years? Yes No
Experience & Qualifications
Traffic Convictions and Forfeitures for the Past Three Years (other than Parking Violations) Include: Location, Date, Charge and Penalty.
* Have you ever been denied a license, permit or privilege to operate a moter vehicle? Yes No		* Has any license, permit or privilege ever been suspended or revoked? Yes No
Equipment Experience
Equipment Experience #1:
Class (Van, Tank, Flat, Etc.)	Type (Truck, Tractor, Semi, Etc)	Experience From	Experience To
Equipment Experience #2:
Class (Van, Tank, Flat, Etc.)	Type (Truck, Tractor, Semi, Etc)	Experience From	Experience To
Equipment Experience #3:
Class (Van, Tank, Flat, Etc.)	Type (Truck, Tractor, Semi, Etc)	Experience From	Experience To
Equipment Experience #4:
Class (Van, Tank, Flat, Etc.)	Type (Truck, Tractor, Semi, Etc)	Experience From	Experience To
Accident Record
Accident Record for the Past Three Years (or More) Include: Date, Nature of Accident(Head-on, Rear-end, etc.), and Fatality/Injury/Non-Injury.
Background Information
* Have you been convicted of a felony within the last 7 years? Yes No
If yes, explain below (conviction will not necessarily disqualify applicant from employment).
Physical Limitations
* Are you able to lift 20 lbs. numerous times throughout the day? Yes No		* Are you able to remain standing for extended periods of time? Yes No
* Are you able to lift up to 50lbs? Yes No		* Are you able to push/pull rolling carts and manual pallet jacks with weight ranging from 150lbs to 300lbs. loads? Yes No
* Are you able to bend or squat repeatedly over an extended period of time? Yes No		* Are you able to perform tasks with your hands/fingers throughout the day(hold, grasp, pick, pinch)? Yes No
If no to any question, what can be done to accommodate your limitation?
Special Skills
Do you have any special skills which you would like to tell us about?
Addresses for Past Three Years
Previous Address #1:
Address	City	State	Zip
Resident From		Until
Previous Address #2:
Address	City	State	Zip
Resident From		Until
Previous Address #3:
Address	City	State	Zip
Resident From		Until
Previous Address #4:
Address	City	State	Zip
Resident From		Until
Previous Address #5:
Address	City	State	Zip
Resident From		Until

Step 3 of 6: Employment History

All drivers applying to drive intrastate or interstate commerce must provide the following information on employers during the preceding three years. List mailing address, street number, city, state and zip code. Applicants applying to drive a "commercial moter vehicle" as defined by Part 383, in intrastate or interstate commerce shall also provide an additional seven years information on those employers for whom the applicant driver operated such vehicle.

(NOTE: List employers as most recent first. Name the supervisor to whom you reported. List dates as month and year)

Employer #1:
Name & Location of Employer
Employed From	Employed Until	Phone
Supervisor		If current, may we contact? Yes No
Position & Responsibilities
Reason for Leaving
Employer #2:
Name & Location of Employer
Employed From	Employed Until	Phone
Supervisor		If current, may we contact? Yes No
Position & Responsibilities
Reason for Leaving
Employer #3:
Name & Location of Employer
Employed From	Employed Until	Phone
Supervisor		If current, may we contact? Yes No
Position & Responsibilities
Reason for Leaving

Release & Confirmation

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the referrals listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, any employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.

* Name:

* Date:

Step 4 of 6: Personal References

Please enter at least two personal references.

Personal Reference #1:
Name	Relation to you	Phone
Personal Reference #2:
Name	Relation to you	Phone
Personal Reference #3:
Name	Relation to you	Phone

Step 5 of 6: Schedule Preferences

* Name	* How many hours per week would you like to work?
Times you are available:
* Monday From:	* Monday To:
* Tuesday From:	* Tuesday To:
* Wednesday From:	* Wednesday To:
* Thursday From:	* Thursday To:
* Friday From:	* Friday To:
* Saturday From:	* Saturday To:
* Sunday From:	* Sunday To:
* If hired, your schedule may or may not use all your available hours.
Additional information about your schedule or events coming up:

Step 6 of 6: Location Preferences

Employee Authorization for Release

You are hereby authorized to give to Kaw Valley Greenhouses, Inc. all information regarding my services, character, and conduct while in your employ, and you are released from any and all liability which may result from furnishing such information to the above named company.

By typing my name below, I understand that this is a virtual representation of my signature, and certifies that this application was completed by me:

* Name:

* Date: