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Pine Ridge Farms is an Equal Opportunity Employer

Position applying for:
Name:	Social Security:
Address:
City:	State: Zip Code:
Phone Day:	Evening:

Are you 18 years old or older: Yes No

Have you ever worked for this company before? Yes No

Referral source: Walk-In Web Site Pine Ridge Farms Employee Other

If offered a position, what date could you begin working?

Are you able to perform the essential functions of the job that you have applied for with or without reasonable accommodations? Yes No

Have you been convicted of a crime within the past seven years? Yes No If yes, what?

(Answering yes to the question does not disqualify you from employment with Pine Ridge Farms.)

Previous experience and employer(s)

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