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Receptionist/ Accounts Receivable/Office Assistant – Imperial, NE

Frenchman Valley Farmers Cooperative, Inc. • Fort Wayne, IN, United States • $200k - $250k / year • 1m ago

– Step 1 of 6

First Name *

Middle Initial

Last Name *

Address *

Address Line 1

Address Line 2

City

State

Have you lived at this address for the past three years?

If “No” please provide addresses for the past three years.

Previous Address

Address Line 1

Address Line 2

City

State

Are you 18 years or older? *

Have you ever applied for employment with us? *

If “Yes”, provide Month, Year, and Location of previous application

Month and Year

Location

Not including religious absences, are you available to work full-time?

If not, what hours can you work?

Home Phone * United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Cell Phone United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Work Phone United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Today's Date *

Email *

Pay Expected

Will you work overtime if asked?

When can you begin work? *

How did you hear about FVC?

Have you ever been bonded?

If “Yes” with what employers?

Are you legally eligible for employment in the United States? *

If you are a citizen or national of the U.S. or a lawful Permanent Resident, you ARE ELIGIBLE for employment.

If you are a non-resident alien (not a citizen or national of the U.S. or lawful Permanent Resident), your ELIGIBILITY FOR EMPLOYMENT ISDEPENDENT UPON YOUR STATUS.

Verification of Identity and Work Authorization
Any offer of employment is contingent upon whether your visa or citizenship status allows you to legally perform the job offered to you. In orderto confirm your eligibility for employment, you must complete the USCIS Employment Eligibility Verifications (Form I-9), which requires you toattest that you are a citizen or national of the U.S., a lawful Permanent Resident or an alien authorized to work, and to provide documents toverify your identity and employment eligibility. Your status will also be confirmed by the Federal E-Verify system. Both of these processes arerequired by law.

Have you been convicted of, or pled guilty or no contest (nolo contendre) to (a) a felony, or (b) a misdemeanor; or (c) are you subject to a court order restraining you from contacting, harassing, stalking or threatening another person? Convictions that have been annulled, expunged, or sealed by a court do not need to be listed. *

If you answered “Yes”, please describe the circumstances of the conviction, plea or event. The existence of a conviction or restraining order identified above is not considered an automatic bar to employment. Frenchman ValleyCooperative will determine if the information is relevant to the position sought depending on the totality of the circumstances.This application does not in any way guarantee applicant an interview or employment

Please list name and location of the last school you attended *

Graduate
College
Business/Trade/Technical
High School
Elementary School

Course of Study

Years Completed

Type: Degree or Diploma?

Please state any special courses that are particularly relevant to the position you are seeking

Please list all other special training or skills (languages, machine operation, etc,)

Have you served in the U.S. Armed Forces? *

If “Yes” what Branch did you serve in and what was your Characterization of Military Discharge? The existence of a dishonorable, bad conduct or a discharge under other than honorable conditions is not considered an automatic bar toemployment. Frenchman Valley Cooperative will determine if the information is relevant to the position sought depending on the totality ofthe circumstances.

Previous Employment

Please give a COMPLETE and accurate description of all full-time and part-time employment. All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip.Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the ap- plicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)

Previous Employment #1 Company Name * Phone * United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Address *

Address Line 1

Address Line 2

City

State

Dates of Employment Start Date * End Date *

Description of Duties

Reason for Leaving

Were you subject to the FMCSRs† while employed?

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Do you wish to add additional employment?

Previous Employment #2 Company Name Phone United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Address *

Address Line 1

Address Line 2

City

State

Dates of Employment Start Date * End Date *

Description of Duties

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 CFR Part 40?

Do you wish to add additional employment?

Previous Employment #3 Company Name Phone United States +1

United States +1
United Kingdom +44
Afghanistan +93
Albania +355
Algeria +213
American Samoa +1
Andorra +376
Angola +244
Anguilla +1
Antigua & Barbuda +1
Argentina +54
Armenia +374
Aruba +297
Ascension Island +247
Australia +61
Austria +43
Azerbaijan +994
Bahamas +1
Bahrain +973
Bangladesh +880
Barbados +1
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +1
Bhutan +975
Bolivia +591
Bosnia & Herzegovina +387
Botswana +267
Brazil +55
British Indian Ocean Territory +246
British Virgin Islands +1
Brunei +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Cape Verde +238
Caribbean Netherlands +599
Cayman Islands +1
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +61
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo - Brazzaville +242
Congo - Kinshasa +243
Cook Islands +682
Costa Rica +506
Croatia +385
Cuba +53
Curaçao +599
Cyprus +357
Czech Republic +420
Côte d’Ivoire +225
Denmark +45
Djibouti +253
Dominica +1
Dominican Republic +1
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Eswatini +268
Ethiopia +251
Falkland Islands +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Greece +30
Greenland +299
Grenada +1
Guadeloupe +590
Guam +1
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +39
Jamaica +1
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Kosovo +383
Kuwait +965
Kyrgyzstan +996
Laos +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libya +218
Liechtenstein +423
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +596
Mauritania +222
Mauritius +230
Mayotte +262
Mexico +52
Micronesia +691
Moldova +373
Monaco +377
Mongolia +976
Montenegro +382
Montserrat +1
Morocco +212
Mozambique +258
Myanmar (Burma) +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
North Korea +850
North Macedonia +389
Northern Mariana Islands +1
Norway +47
Oman +968
Pakistan +92
Palau +680
Palestine +970
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Poland +48
Portugal +351
Puerto Rico +1
Qatar +974
Romania +40
Russia +7
Rwanda +250
Réunion +262
Samoa +685
San Marino +378
Saudi Arabia +966
Senegal +221
Serbia +381
Seychelles +248
Sierra Leone +232
Singapore +65
Sint Maarten +1
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
South Korea +82
South Sudan +211
Spain +34
Sri Lanka +94
St Barthélemy +590
St Helena +290
St Kitts & Nevis +1
St Lucia +1
St Martin +590
St Pierre & Miquelon +508
St Vincent & Grenadines +1
Sudan +249
Suriname +597
Svalbard & Jan Mayen +47
Sweden +46
Switzerland +41
Syria +963
São Tomé & Príncipe +239
Taiwan +886
Tajikistan +992
Tanzania +255
Thailand +66
Timor-Leste +670
Togo +228
Tokelau +690
Tonga +676
Trinidad & Tobago +1
Tunisia +216
Turkey +90
Turkmenistan +993
Turks & Caicos Islands +1
Tuvalu +688
US Virgin Islands +1
Uganda +256
Ukraine +380
United Arab Emirates +971
United Kingdom +44
United States +1
Uruguay +598
Uzbekistan +998
Vanuatu +678
Vatican City +39
Venezuela +58
Vietnam +84
Wallis & Futuna +681
Western Sahara +212
Yemen +967
Zambia +260
Zimbabwe +263
Åland Islands +358

Address *

Address Line 1

Address Line 2

City

State

Dates of Employment Start Date * End Date *

Description of Duties

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 CFR Part 40?

Additional Employment Click or drag a file to this area to upload.

Membership in professional and civic organizations, special accomplishments, awards, etc. Exclude those which may disclose your race, color, religion, age, marital status, disability or national origin.

This section needs to be filled out by any person seeking employment that will require driving of any type (pickups, machinery, trucks, etc.)

If you are not applying for a position that will require driving, please skip this section.

Drivers Licenses

List all driver licenses or permits held in the past 3 years.

Driver's License #1 State License Number Type Expiration Date

Do you wish to add another driver's license?

Driver's License #2 State License Number Type Expiration Date

Do you wish to add another driver's license?

Driver's License #3 State License Number Type Expiration Date

Additional Driver's Licenses Click or drag a file to this area to upload.

Driving Experience

Driving Experience #1 Class of Equipment

Straight Truck
Tractor & Semi-Trailer
Tractor-Two Trailers
Other

Type of Equipment (van, tank, flat, etc.)

Start Date

End Date

Approx. # of Total Miles

Do you wish to add additional driving experience?

Driving Experience #2 Class of Equipment

Straight Truck
Tractor & Semi-Trailer
Tractor-Two Trailers
Other

Type of Equipment (van, tank, flat, etc.)

Start Date

End Date

Approx. # of Total Miles

Do you wish to add additional driving experience?

Driving Experience #3 Class of Equipment

Straight Truck
Tractor & Semi-Trailer
Tractor-Two Trailers
Other

Type of Equipment (van, tank, flat, etc.)

Start Date

End Date

Approx. # of Total Miles

Do you wish to add additional driving experience?

Driving Experience #4 Class of Equipment

Straight Truck
Tractor & Semi-Trailer
Tractor-Two Trailers
Other

Type of Equipment (van, tank, flat, etc.)

Start Date

End Date

Approx. # of Total Miles

Additional Driving Experience Click or drag a file to this area to upload.

Accident record for the past three years or more, with most recent accident listed first. If none, leave blank.

Accident History #1 Date Nature of Accident (head-on, rear-end, upset, etc.) Fatalities Injuries

Do you wish to add additional accident history?

Accident History #2 Date Nature of Accident (head-on, rear-end, upset, etc.) Fatalities Injuries

Do you wish to add additional accident history?

Accident History #3 Date Nature of Accident (head-on, rear-end, upset, etc.) Fatalities Injuries

Additional Accident History Reports Click or drag a file to this area to upload.

Traffic Convictions and Violations

Traffic convictions and forfeitures for the past 3 years (other than parking violations). If none, leave blank.

Traffic Conviction / Violation #1 Location Date Charge Penalty

Do you wish to add an additional traffic conviction / violation?

Traffic Conviction / Violation #2 Location Date Charge Penalty

Do you wish to add an additional traffic conviction / violation?

Traffic Conviction / Violation #3 Location Date Charge Penalty

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Has any license, permit or privilege ever been suspended or revoked?

IF THE ANSWER TO EITHER OF THESE QUESTIONS IS YES, ATTACH A STATEMENT GIVING DETAILS. Click or drag a file to this area to upload.

Please read and understand this statement before signing your application:

The information I have provided in this Application for Employment is true, correct and complete. False, incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and obtain information about me from previous employers, educational institutions, and “references” I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organiza- tions who provide information for this purpose.

This application will expire in 30 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application.

This application is not an employment agreement. If I accept an offer of employment I understand I may resign at any time, and the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Pre-Employment Urinalysis Consent: I understand as a condition of employment with Frenchman Valley Coop I must submit to a controlled substance test. A urine sample will be collected and tested for controlled substances. I also understand that if I test positive for use of controlled substances, I will not be considered for employment with Frenchman Valley Coop.