APPLICANT ANIMAL INFORMATION

Applicant Name ________________________________________________________________________

Household Pets
It must be established before beginning employment that an applicant does not have certain animals in the
household. Taconic has established this policy because there are certain animal bacteria and viruses that can be
carried by humans from animals raised in non-restrictive areas, which could unknowingly be transferred to our
animals. These bacteria and viruses pose no danger to humans, but could severely affect the health and salability
of our animals.
It is unacceptable for our employees or their household members to store or have as pets any of the following
animals in their home or on their property, or be in direct contact with these animals at any time during their
employment with Taconic Farms. This is not a comprehensive list, and it is your responsibility to ask if you are not
sure whether a pet is allowed. The following are examples of prohibited pets:
Mice
Rats
Guinea pigs
Hamsters

Gerbils
Rabbits
Chinchillas
Other rodents

Snakes
Carnivorous reptiles
Birds of prey
Other animals that eat rodents as their source of nutrition

If an applicant has any of these animals living in the household, the animal must be removed from the property at
least seven calendar days prior to beginning work, should an offer of employment be made.
1. Do you have any of the above listed animals in your household?
1a. If yes, are you willing to find another home for the animal?

Yes

No

Yes

No

2. Please list all animals currently residing in your household or on your property: _____________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Animal Rights Organizations

Are you now, or have you ever been, a member or supporter of an animal rights organization or other organization
aimed at stopping, minimizing, or eliminating animal research?
Yes

No

If yes, please explain: ______________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Signed ____________________________________________ Dated ___________________________

Revised 04-01-07

APPLICANT EMPLOYMENT HISTORY

APPLICANT NAME:
________________________________________________________________________________________
Have you ever been convicted of a crime? YES NO

If yes, please explain.______________________

________________________________________________________________________________________
EDUCATIONAL BACKGROUND:
School ____________________________________________________ Graduated

YES

NO

Major _____________________________________________________ Years Completed ____________

School ____________________________________________________ Graduated

YES

NO

Major _____________________________________________________ Years Completed ____________

WORK HISTORY (List most recent employer first)
Employer __________________________________________________ Dates ______________________
Address ___________________________________________________ Supervisor___________________
Position ___________________________________________________ Pay Rate ____________________
Duties ___________________________________________________________________________________
Why did you leave? ______________________________________________________________________
May we contact for a reference?
YES
NO
Employer _________________________________________________ Dates _______________________
Address __________________________________________________ Supervisor____________________
Position ___________________________________________________ Pay Rate ____________________
Duties ___________________________________________________________________________________
Why did you leave? ______________________________________________________________________
May we contact for a reference?
YES
NO
Employer ________________________________________________ Dates ________________________
Address _________________________________________________ Supervisor_____________________
Position ___________________________________________________ Pay Rate ____________________
Duties ___________________________________________________________________________________
Why did you leave? ______________________________________________________________________
May we contact for a reference?
YES
NO

Revised 04-01-07

EQUAL EMPLOYMENT OPPORTUNITY DATA

IMPORTANT - To all applicants: to enable us to meet government reporting regulations and maintain an
Affirmative Action Plan, Taconic, Farms, Inc. requests that you complete this personal data form. Information
will be used solely for government reporting purposes and will be detached and kept separate from your
application. Any information that you choose to provide will not be considered by Taconic Farms, Inc. for
employment purposes and will be treated as personal and confidential. Your voluntary cooperation will be
appreciated. If you have voluntarily completed this form previously in the current application process there is
no need to complete an additional form.

Name:

__________________________________________________________________
Last

First

Initial

Position: __________________________________________________________________
Date:

____________________________________ Male

_______

Female _______

If any of these definitions apply to you, please check off the appropriate box to be considered
under our Affirmative Action Plan.
Ethnic/Racial Category
_____ Hispanic or Latino
_____ American Indian or Alaska Native Not Hispanic or Latino
_____ Asian Not Hispanic or Latino
_____ Black or African American Not Hispanic or Latino
_____ Native Hawaiian or Other Pacific Islander Not Hispanic or Latino
_____ White Not Hispanic or Latino
_____ Two or more races Not Hispanic or Latino

RERERRAL SOURCE
_____ Advertisement
_____ Employee Referral
_____ Unsolicited Resume
_____ Government Agency
_____ Employment Agency
_____ College Recruitment
_____ Walk-In
_____ Open House
_____ Other

Revised 04-01-07

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9) Please describe: ___________________________________

APPLICANT REFERENCE AUTHORIZATION

To applicant: Please complete only the information in this box. Leave the remainder of the form blank.
Applicant Name: _________________________________ Social Security No.: ______________________
Address: ________________________________________________________________________________
Position Applied For: _____________________________________________________________________
My signature authorizes Taconic to obtain information from all references, employers, public agencies, licensing
authorities, and educational institutions provided by me in my application for employment, resume, or job interview. I
hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives,
for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process,
and all other persons, corporations, or organizations for furnishing such information about me. I certify that all information
I have provided while applying for employment with Taconic Farms is true, complete, and accurate.

I authorize the individual or company named below

_________________________________________
to furnish Taconic with the information requested.

Signature of Applicant

Date

The above named applicant has applied for employment with Taconic Farms, Inc. and has indicated that you can provide
a reference. We would appreciate your verifying information he/she has provided, as well as answering some general
questions in regard to his/her employment. We assure you that any information you supply will be held in strictest
confidence, except where required by law.
Thank you for your assistance.
Taconic Farms Representative:_________________________________________ Date __________________

Company Name:______________________________________ Phone: ____________________________

Contact Name: _______________________________________ Title: ______________________________
Employed as: ________________________________________ From: ____________ To: _____________
Reason for Leaving:______________________________________________________________________
Would you re-employ? ___________________________________________________________________
Excellent

Good

Average

Fair

Poor

Attendance
Punctuality
Work Attitude
Cooperation
Overall Ability
Recommendation

Comments:______________________________________________________________________________
_________________________________________________________________________________________

Signature of Person Providing Reference: _____________________________ Date ______________

Revised 04-01-07

APPLICANT REFERENCE LIST

Applicant Name __________________________________________________________________________
Please list the name, title, telephone number, and email address of three business, work,
or professional references. Please list people who are not related to you.
Contact #1
Name ____________________________________ Title ____________________________
Relationship to you ________________________________________________________________
Address _________________________________________________________________________
Telephone ________________________________ Email _________________________________

Contact #2
Name ____________________________________ Title ____________________________
Relationship to you ________________________________________________________________
Address _________________________________________________________________________
Telephone ________________________________ Email _________________________________

Contact #3
Name ____________________________________ Title ____________________________
Relationship to you ________________________________________________________________
Address _________________________________________________________________________
Telephone ________________________________ Email _________________________________

Revised 04-01-07

APPLICANT STATEMENT

Applicant Name: ___________________________________________________________________________

Social Security No.: _________________________________________________________________________
Address: __________________________________________________________________________________
Position Applied For: ________________________________________________________________________

I certify that all information I have provided in order to apply for and secure work is true, complete, and
accurate.
I expressly authorize, without reservation, the employer, its representatives, employees, or agents to
contact and obtain information from all references (personal and professional), employers, public
agencies, licensing authorities, and educational institutions to otherwise verify the accuracy of all
information provided in this application, resume, or job interview. I hereby waive any and all rights and
claims I may have regarding the employer, its agents, employees or representatives, for seeking,
gathering and using truthful and non defamatory information, in a lawful manner, in the employment
process and all other persons, corporations, or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this
application is used for the purpose of limiting or eliminating any applicant from consideration for
employment on any basis prohibited by applicable local, state, or federal law.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without
prior notice, and the employer reserves the same right to terminate my employment at any time, with or
without cause and with or without prior notice, except as may be required by law. This application does
not constitute an agreement or contract for employment for any specified period or definite duration. I
understand that no supervisor or representative of the employer is authorized to make any assurances
to the contrary and that no implied oral or written agreements contrary to the foregoing express
language are valid unless they are in writing and signed by the employer's president.
I also understand that if I am hired, I will be required to produce documents to provide proof of identity
and legal authorization to work within the United States, and that federal immigration laws require me to
complete an I-9 Form in this regard.
I understand that any misrepresentation, falsification, or material omission of information on my
application, resume, during an interview, or any supplement thereto may result in eliminating me from
further consideration or, if I am hired, in my dismissal from employment.
__________________________________________________________________________________________
Signature of Applicant
Date

Revised 04-01-07