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Employment Application
Name: Buechele Last Telephone: 1-641-381-0300 Address:
Dylan

COMPANY OR EMPLOYER NAME:

Chow Farms

Position applying for:

Tractor Driver

EMPLOYEE INFORMATION
Scott

First Email: 14dbuechele@nkstudents.com

Middle Alternate telephone: 1-641-324-0515

98 Shellrock Drive Northwood, Iowa 50459

Are you able to perform the essential functions of the position with or without accommodations?
Yes 14 18 Yes No 15 19 No Yes No 16 21 (Check one)

If necessary for the job are you older than:

If necessary for the job, I am able to: Yes No Work overtime? Yes No Provide a valid Alaska Driver's License? Iowa If so, fill out the following: Issuing state: Type: Endorsement(s):
Hazardous Material Tankers School Bus Any Split Day Night Other: Passengers Tank with Hazardous Materials Double/Triple trailers Swing Rotating

I am legally eligible for employment in the U.S.? I am seeking a permanent position:

Work the following shifts: (check all that apply)

Graveyard

I will be able to report to work 14 days after being notified I am hired.

EMPLOYMENT HISTORY
List most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary. No more than 10 years history recommended.

Employer name and address:

City of Northwood 627 Central Ave. Northwood, Iowa 50459

Position title/duties, skills:

Mow and up-keep the city cemetery and other parks through out the city of Northwood.

Start date: End date: 5/30/2013 8/18/2013 Reason for leaving: Summer employment only.

Pay: $ 11.50 Per: HOUR Employer name and address:

Supervisor: RICHARD BUTLER Position title/duties, skills:

Telephone: 1-641-324-1075 Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: Per: $ Supervisor: Telephone:

Employment Application Page 1 of 2

Rev. 8/2010

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Summarize other employment related to this job:

EDUCATION
Institution name High school College/university Business/technical Additional Years completed Field of study Graduate or degree
Working towards diploma

Northwood High school

3 1/2

General studies.

MILITARY
Are you a veteran? Duty/specialized training: Yes
]

No

SKILLS & QUALIFICATIONS

Other qualifications such as special skills, abilities or honors that should be considered: Mechanical Skills Types of computers, software, and other equipment you are qualified to operate or repair: Farm Gps's. Professional licenses, certifications or registrations:
Comeralcial chemical application license.

Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employers attention: Typing speed: 15 per minute

REFERENCES
List two personal references who are not relatives or former supervisors.
Eric Scheafer Name Marty Cotter Name

97 Shellrock Drive, Northwood, Iowa 50459

Address
2057 490th Street, Northwood, Iowa 50459 Address

641-324-5429 Telephone
641-390-1147 Telephone

Factory Worker
Occupation

10
Years known

Teacher
Occupation

5
Years known

CONTACT
In case of accident or illness, please contact: Name: Andrew Buechele Address: 98 Shellrock Drive, Northwood, Iowa 50459 Daytime phone: 1-641-430-1235 Relationship: Father

INFORMATION TO THE APPLICANT

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.

February 9th.

Signature of Applicant

Date

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment. Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division. Rev. 8/2010 Employment Application Page 2 of 2