SCHILTZ HARVESTING                                                    PHONE (785) 386-4438----FAX (785) 386-4439
 PO BOX 55                                                                       wheat@ruraltel.net
 SELDEN, KS  67757                                                          schiltzharvesting.com

EMPLOYEE INFORMATION:

NAME: _____________________________________________  DATE: _______________________________

ADDRESS: _______________________________________________________________________________

PHONE NUMBER (S):  _______________________________________________________________________

E-MAIL ADDRESS: _________________________________________________________________________

DATE OF BIRTH: _________________________   MARITAL STATUS: ________________________________

SS#: _______________________  DRIVER'S LICENSE# AND STATE: _______________________________

EMERGENCY CONTACT: (NAME)____________________________________(ADDRESS)_________________

_________________________________________(PHONE)_________________________________________

ARE YOU AN AMERICAN CITIZEN?                                                                     YES_____     NO____
       IF NO, ARE YOU AUTHORIZED TO WORK HERE?                                           YES_____     NO____
ANY HEALTH PROBLEMS OR SPECIAL NEEDS?                                                     YES_____     NO____

       IF YES, EXPLAIN: ______________________________________________________________________
ANY DISABILITIES?                                                                                          YES_____     NO____

       IF YES, EXPLAIN: ______________________________________________________________________

WHEN WAS YOUR LAST TETANUS SHOT? _______________________________________________________

DO YOU HAVE A CDL DRIVER'S LICENSE?                                                           YES_____     NO____
HAVE YOU EVER BEEN CHARGED WITH A DUI?                                                    YES_____     NO____
HAVE YOU EVER BEEN CHARGED WITH ANY FELONY?                                           YES_____     NO____
HAVE YOU EVER BEEN IN A JOB RELATED ACCIDENT?                                          YES_____     NO____
DO YOU HAVE SPEEDING TICKETS ON YOUR RECORD?                                        YES_____     NO____
IF YES TO ANY OF THE ABOVE, EXPLAIN: ______________________________________________________

________________________________________________________________________________________

HIGHEST LEVEL OF EDUCATION: _____________________________________________________________
LIST LAST 3 EMPLOYERS, CONTACT INFORMATION, AND REASON FOR LEAVING THE JOB:

1._______________________________________________________________________________________

_________________________________________________________________________________________

2._______________________________________________________________________________________

_________________________________________________________________________________________

3._______________________________________________________________________________________

_________________________________________________________________________________________

LIST 3 PERSONAL REFERENCES AND PHONE NUMBERS:

1._______________________________________________________________________________________

2._______________________________________________________________________________________

3._______________________________________________________________________________________

WHAT DO YOU EXPECT TO GAIN FROM THIS EXPERIENCE? ________________________________________

_________________________________________________________________________________________

WILL YOU BE ABLE TO COMMIT TO THE FULL SEASON? ___________________________________________
ANY FALSE ANSWERS ON THIS APPLICATION WILL LEAD TO DISMISSAL IF YOU ARE HIRED. BY SIGNING
YOUR NAME BESIDE THE YES, YOU HAVE ACKNOWLEDGED THIS FACT.    YES_________________________