Agfinity, Inc. EMPLOYMENT APPLICATION

Position Applied For: ___________________________________________________

Interested In: Full Time Part-Time Seasonal Internship

Last Name First Name Middle

Address City State Zip Code

Phone Email Address

Are you at least 18 years of age? (If not, you will be required to provide a copy of your work permit.)

YES

NO

Can you provide documentation to verify your identity and legal authority to work in the United States?

YES

NO

Have you ever been convicted of, plead guilty or no contest to a misdemeanor or a felony, or been convicted in a military court martial? YES NO (A yes answer to the above question does not necessarily disqualify an applicant from employment.) If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________

YES NO Have you been employed by Agfinity before?

If yes, when? ________/________/_______ - ________/________/________

How did you hear about Agfinity employment opportunities?

www.agfinityinc.com

Online Job Posting: _________________Newspaper: _______________________

Employee Referral: ______________________

Other: _________________________________

Circle Highest Grade Completed:

High School: 1 2 3 4 College: 1 2 3 4

H.S. Diploma

GED

Certificate

Associates Bachelors

Masters

PHD

Major:____________________

Minor:____________________

EDUCATION INFORMATION

PERSONAL INFORMATION

260 Factory RoadEaton, CO 80615970-454-4000careers@agfinityinc.com

Please provide the following information on all employers during the previous 3 years, beginning with your most recent. If you were self-employed, give firm name. CDL Applicants: You must give the same information for all employers you have

driven a commercial motor vehicle for the 7 years prior to the initial 3 years (total of 10 years employment record). Attach additional sheets if necessary.

Have you ever been dismissed or asked to resign from any position? YES NO

Name of Employer:______________________________________________________________________________

Job Title:_________________________________________________________________________

Start Date: ________/________/_______ End Date: _________/_________/_________

Supervisor’s Name and Title: ______________________________

Address:_________________________________________________________________________

Telephone Number(______)________-____________

Reason for leaving or wanting to leave:____________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

Name of Employer:______________________________________________________________________________

Job Title:_________________________________________________________________________

Start Date: ________/________/_______ End Date: _________/_________/_________

Supervisor’s Name and Title: ______________________________

Address:_________________________________________________________________________

Telephone Number(______)________-____________

Reason for leaving or wanting to leave: ___________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

Name of Employer: _____________________________________________________________________________

Job Title:_________________________________________________________________________

Start Date: ________/________/_______ End Date: _________/_________/_________

Supervisor’s Name and Title: ______________________________

Address:_________________________________________________________________________

Telephone Number(______)________-____________

Reason for leaving or wanting to leave: ___________________________________________________________________

WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY

REGULATIONS WHILE EMPLOYED BY THIS EMPLOYER?

YES NO

WERE YOU REQUIRED TO UNDERGO D.O.T REGULATED DRUG &

ALCOHOL TESTING?

YES NO

EMPLOYMENT INFORMATION

The following sections are only to be completed as a requirement for CDL/Driving positions

Experience and Qualifications (Drivers Only) Section 383.21 FMCSR states “No person who operates a commercial vehicle shall at any time have more than one driver’s

license.” I certify that I do not have more than one motor vehicle license, the information for which is listed below.

Driver Licenses

STATE LICENSE NUMBER TYPE EXPIRATION DATE

Driving experience If none, write NONE

Class of Equipment Type of Equipment (Van, Tank, Flat, Etc.)

Dates Approx. Number of Miles (Total) TO FROM

Straight Truck

Tractor & Semi – Trailer

Tractor – Two Trailers

Other

Accident record for past 3 years or more (attach sheet if more space is needed)

DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, ETC)

# OF FATALITIES

# OF INJURIES CHEMICAL SPILLS

YES NO

YES NO

YES NO

Traffic convictions & forfeitures for the past 3 years (other than parking violations)

DATE CONVICTED

VIOLATION STATE OF VIOLATION LOCATION

PENALTY (FORFEITED BOND, COLLARTERAL

AND/OR POINTS)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO

B. Has any license, permit or privilege ever been suspended or revoked? YES NO

If the answer to A or B is ‘yes’, please explain (ATTACH ADDITIONAL SHEETS IF MORE SPACE IS NEEDED):

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety – sensitive transportation, work covered by DOT agency drug & alcohol

testing rules during the past two years? YES NO

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical

history and other related matters as may be necessary in arriving at an employment decision. I hereby release

employers, schools, health care providers and other persons from all liability in responding to inquiries and

releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s)

may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Agfinity, Inc.

“I understand that information I provide regarding current and/or previous employers may be used, and those

employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR

391.23(d) and (e). I understand that I have the right to:

Review information provided by current/previous employers Have errors in the information corrected by previous employers and for those previous employers to re-send the

corrected information to Agfinity, Inc. Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot

agree on the accuracy of the information.”

______________________________ ________________________________________________________________

DATE APPLICANT’S SIGNATURE

CERTIFICATION AND TERMS

I certify that all of the information I have given in completing this application is true and complete. I further understand that Agfinity, Inc. may refuse employment or discharge me during employment if I have given false or misleading information or omissions in this application.

In signing this application, I give my permission to Agfinity, Inc. to perform an investigation either by direct or indirect means that may involve all or some of the following: previous employment, education, credit record***, driving record, criminal history, and skill verification. I further authorize any individual, previous employer, institution, or company to provide such information and release such party(s) including Agfinity, Inc. from any and all liability that might otherwise be incurred in furnishing such information, subject to federal and state law.

I understand and agree that if employed, the employment will be “at will”. This means that either Agfinity, Inc. or I may end the employment relationship at any time, for any reason, or no reason. I further understand that receipt of this application by Agfinity, Inc. does not imply employment nor is this application a contract of employment. I understand that no Agfinity, Inc. representative has the authority to alter the “at will” nature of this employment absent written authorization of the C.E.O.

I further understand that if employed, I may be required to voluntarily submit to a drug test and physical as directed by Agfinity, Inc. for any of the following: (a) a drug/alcohol screening after hire but before starting work, (b) a random drug/alcohol test legally required in your job, e.g. DOT, (c) a random drug/alcohol test as required by Agfinity, Inc., (d) a drug/alcohol test after involvement in an “on the job” industrial or vehicular accident, (e) a drug/alcohol test after an occurrence of “probable cause”. If I refuse to take a drug/alcohol or physical test, I understand that an offer of employment may be withdrawn or my employment terminated by Agfinity, Inc..

***If a credit report is requested and information on that report is used by the Company, which adversely affects

you, the Company will furnish you with a copy of that report and your rights under the “Fair Credit Reporting

Act.”

_________________________________________ _________/_________/_______

Signature Date

_________________________________________

Please Print your Name