Name *

First Name

Last Name

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you 18 or older? *

Yes

No

Are you either a U.S. citizen or a foreign citizen authorized to work in the U.S.? *

Yes

No

Can you perform the physical requirements of the job? *

Yes

No

Have you been employed by Medford Food Co-op before?

Yes

No

On what date are you available to start? *

MM

DD

YYYY

When are you available to work? *

Please check all that apply.

Full-time

Part-time

Temporary

Weekdays

Weekends

Mornings

Days

Evenings

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone *

(###)

###

####

Supervisor *

First Name

Last Name

Date Hired *

MM

DD

YYYY

Date Left *

MM

DD

YYYY

Do you still work for this employer? *

Yes

No

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Supervisor

First Name

Last Name

Date Hired

MM

DD

YYYY

Date Left

MM

DD

YYYY

Do you still work for this employer?

Yes

No

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Supervisor

First Name

Last Name

Date Hired

MM

DD

YYYY

Date Left

MM

DD

YYYY

Do you still work for this employer?

Yes

No