Application to Join Us...

Name*

Phone*Street Address*

City* State* Zip code*

Position Desired* Salary Requested

When can you be available to begin? Month/Day/Year

What time of day would you like to work?

Are you interested in full-time or part-time work?

How were you referred to Rolling Fields.

Were you ever employed by us in the past? Yes No Please explain if yes.

List any friends or relatives employed by Rolling Fields

RECORD OF EDUCATION

School	Name & Address of School	Course of Study	Highest Grade Completed	Did you Graduate?	List diploma or degree

:List other skills, experiences or qualifications which you feel would especially benefit our team

RECORD OF EMPLOYMENT

Dates Employed	Name & Address of employer	Job Title	Salary	Reason for Leaving	Supervisor's Name

Which of these jobs did you like best and why?

Which of these jobs did you like least and why?

Give a brief description of the work performed & your responsibilities in the positions mentioned above

Have you ever been convicted of or pled guilty to a felony or misdemeanor? Yes No If yes please explain?

Have you lived in Pennsylvania for the last two years? Yes No If no, please tell us where you lived.

Do you have a legal right to work in the United States? Yes No

“ Under the Immigration Control and Reform Act of 1986, any new employee (whether U.S. Citizen or resident alien) must provide at the time of employment, proof of identity, such as a driver’s license with photograph, and authorization to be employed, i.e. birth certificate, social security card, U.S. passport, certificate of U.S. Citizenship or naturalization, resident alien card. If an employee is not able to do so, the employee will be discharged immediately. “

PERSONAL REFERENCES

Full Name	Address	Phone	Occupation	Years Known

applicant:__ read this information carefully before signing

In connection with my application for employment with Rolling Fields, (the “Company” ), I hereby certify that the information submitted by me on this application, resume and during my personal interview is true and complete to the best of my personal knowledge, and I understand that any false information, omissions or misrepresentation of fact called for in this application, resume and/or personal interview whether intended or unintended, may be cause for the denial of my application or, if I am employed, immediate discharge.

I am applying for a position with Rolling Fields and in connection therewith, I understand that the “Company” may contact my previous employers, neighbors, friends, acquaintances and associates in order to obtain information regarding my prior job performance or my qualifications for employment. I further understand that all reference information will remain confidential and will not be shared with me. I release the “Company” and all parties contacted by Rolling Fields, from any liability whatsoever concerning the information supplied by them to Rolling Fields.

Prior to final consideration for hire, the I will be required to take and successfully pass a post-offer of employment physical, a PPD screening for tuberculosis and a criminal history background check. I understand that a criminal history background check will be requested from the PSP and/or the FBI. I also understand that my employment is provisional and continued employment is based upon the information to be received from the criminal justice agency. If the clearance request indicates convictions for crimes that prohibit my employment under Act 169 of 1996 and Act 13 of 1997, I understand that my employment must be terminated in compliance with state law. To the best of my knowledge I have never been convicted of a crime that would prohibit my employment at Rolling Fields, Inc

I also understand that this is NOT a secure website and I can send my resume and information via US mail to the address below if I do not wish to submit this information over an unsecured network. (Rolling Fields 9108 State Hwy. 198 Conneautville, PA 16406)

By typing my name here I understand all above information and wish to be contacted with regard to my employment interest.*

Federal and state laws prohibit discrimination on the basis of sex, race, creed, religion, color, national origin, citizenship,
sexual orientation, age in accordance with applicable law, handicap, disability, medical condition marital and veterans
status in all practices, privileges and conditions of employment. Rolling Fields strictly adheres to these laws and will
consider all qualified applicants for employment without regard to any of these factors. All fields marked with are required!*