Last Name: First Name: MI:

Address: City: State: Zip Code:       

Home Phone: Work Phone:    E-mail Address:

-Are you at least 18?  Yes     or     No 

-Are you prevented from lawfully becoming employed in this country because of VISA or immigration status?   Yes      or      No

-Can you, after employment, submit proof of citizenship and age?   Yes    or     No

-Have you ever worked for this company?    Yes    or     No

-Are you acquainted with anyone at Heimerl Farms Ltd., Heimerl Farms Inc., Mad River Swine LLC., or Eagle Creek Swine LLC?  Yes     or      No      *If yes, Names and relationship:

- Have you been convicted of a Felony in the past 7 Years?  Yes     or     No

-Have you ever been discharged or suspended for cause?   Yes     or      No    *If yes, explain:

EDUCATION:

High School Name:    Did you graduate? Graduated with a Diploma Only attended 11 years Only attended 10 years Only attended 9 years

College Name:    Years attended: Did not attend College Graduated with a Diploma Attended College for 3 years Attended College for 2 years Attended College for 1 year Major:

Did you attend Graduate School? Yes No      Did you attend Vocational School? Yes No

REFERENCES:

Please include names and addresses of three references. (Please exclude relatives):

Reference #1: *Please erase the current text box data and apply your reference as shown below.

John Doe Owner of Rons Auto 614-123-4567 Anytown, OHIO

Reference #2: *Please erase the current text box data and apply your reference as shown below.

John Doe Owner of Rons Auto 614-123-4567 Anytown, OHIO

Reference #3: *Please erase the current text box data and apply your reference as shown below.

John Doe Owner of Rons Auto 614-123-4567 Anytown, OHIO

EMPLOYMENT HISTORY: (Please list most recent employer first)

Employer #1: *Please erase the current text box data and apply your prior employer as shown below.

Company Name Supervisor Name 11334 Anyroad St. Anytown, OH 45177 614-123-4567

Title and Responsibilities: ex. Auto Mechanic - parts technician

Employment Dates (From and To): ex. 01/03/1990 - 02/05/2005

Starting Salary: ex. $8.00      Ending Salary: ex. $8.00

Employer #2: *Please erase the current text box data and apply your prior employer as shown below.

Company Name Supervisor Name 11334 Anyroad St. Anytown, OH 45177 614-123-4567

Title and Responsibilities:  ex. Auto Mechanic - parts technician

Employment Dates (From and To):  ex. 01/03/1990 - 02/05/2005

Starting Salary: ex. $8.00       Ending Salary: ex. $8.00

By submitting this form, the above stated applicant certifies that answers given herein are true to the best of his/her knowledge.

In the event of employment, the applicant understands that false or misleading information given in this application or interview(s) may result in refusal to hire, or, if employed, may subject the applicant to be discharged at any time after discovery. If employed, the applicant agrees to abide by all rules and regulations of the Company in effect from time to time.

By submitting this form, the applicant hereby acknowledges that any employment relationship with this company is of an "at will" nature, which means that the applicant may resign at any time, and the Company may discharge the applicant at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged as applying to the applicant in writing by the President/CEO of the Company.

*Please press "submit" after you have successfully completed the form entirely. You will receive a confirmation your application has been received within 72 hours of submission. Thank You. Questions regarding the hiring process can be answered by submitting a feedback form, or by calling the main office at: (740)-967-0063.