Job Application

721 S. STATE STREET, UKIAH, CA 95482-5815
(707) 462-4778
Email to: swinter@ukiahcoop.com

PERSONAL INFORMATION:

Full Name:____________________________________________________________________

Present Address:________________________________________________________________

City_______________________________State________Zip Code________________________

Mailing Address (if different)______________________________________________________

City_______________________________State________Zip Code________________________

Telephone Number:_____________________________________________________________

Are you eligible to work in the United States? Yes or No

Have you ever been convicted of a felony? Y or N If yes, what charge___________________

Are you 18 years of age or older? Y or N If no, what is your age _____________________

EMPLOYMENT HISTORY: List employers, starting with the most recent.

_____ Employer__________________________________________________

Dates:_______________Supervisor:_____________________________Telephone____________

From_____to_____ Address_____________________________________________________

Pay Rates: City_________________________State____________Zip Code_______

________/________

Responsibilities:________________________________________________________________
______________________________________________________________________________

Reason for Leaving:_____________________________________________________________

______________________________________________________________________________

May we contact this employer? Yes or No

_____ Employer__________________________________________________

Dates:_______________Supervisor:_____________________________Telephone____________

From_____to_____ Address_____________________________________________________

Pay Rates: City_________________________State____________Zip Code_______

________/________

Responsibilities:________________________________________________________________
______________________________________________________________________________

Reason for Leaving:_____________________________________________________________

______________________________________________________________________________

May we contact this employer? Yes or No

_____ Employer__________________________________________________

Dates:_______________Supervisor:_____________________________Telephone____________

From_____to_____ Address_____________________________________________________

Pay Rates: City_________________________State____________Zip Code_______

________/________

Responsibilities:________________________________________________________________
______________________________________________________________________________

Reason for Leaving:_____________________________________________________________

______________________________________________________________________________

May we contact this employer? Yes or No

EDUCATION: List name and location of schools.

Last Grade Completed____________________________________________________________

Currently Enrolled?_______________________________________________________________

Area of Study__ ________________________________________________________________

Other Schooling (Specify)_________________________________________________________

______________________________________________________________________________

Ukiah Natural Foods is a member-owned-and-operated cooperative. Everyone is welcome
to shop here. Ukiah Natural Foods is committed to providing high-quality food and products.
We are a community-centered cooperative business that supports humane, ecological, social,
educational and economic practices. We are dedicated to prosper and grow in ways that are
consistent with these values.

What position are you applying for:_________________________________________________

How did you hear about this open position:___________________________________________

What days or hours are you available to work?_______________________________________

____________________________________________________________________________

EMPLOYMENT SKILLS: List the skills and experience you have that pertain to the position
for which you are applying:

______________________________________________________________________________

I understand that employment will be contingent upon meeting the criteria required for employment by
Ukiah Natural Foods that includes a background check consisting of a county criminal and state
sex offender search, social security number/address check, and previous employment verification.
I certify that all the information I have given is true and complete. I authorize investigation of all
statements in this application. I understand that Ukiah Natural Foods is an AT WILL employer
and employment can be terminated at any time. All present or former employers will be contacted
unless otherwise specified.

Signature________________________________________ Date__________________________