Previous Employment:

Previous Employer Start Date End Date Rate of Pay Reason for Leaving

__________________ ___/___/___ ___/___/___ $_______ _______________

Address: ________________________________ City: ___________________ State: ______

Zip: ______-______ Phone#:(___) _____-______ Can Be Called? YES ____ NO _____

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Previous Employer Start Date End Date Rate of Pay Reason for Leaving

__________________ ___/___/___ ___/___/___ $_______ _______________

Address: ________________________________ City: ___________________ State: ______

Zip: ______-______ Phone#:(___) _____-______ Can Be Called? YES ____ NO _____

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Previous Employer Start Date End Date Rate of Pay Reason for Leaving

__________________ ___/___/___ ___/___/___ $_______ _______________

Address: ________________________________ City: ___________________ State: ______

Zip: ______-______ Phone#:(___) _____-______ Can Be Called? YES ____ NO _____

Character References:

List people who know you well (>2 years) and are not related to you.

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Name Occupation Telephone Number Years Known

______________________ ________________ (___) ____-_______ ___________

______________________ ________________ (___) ____-_______ ___________

______________________ ________________ (___) ____-_______ ___________

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I understand that this application will be given every consideration, but is not a promise of employment. I understand that if I am

hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I

have the right to terminate my employment at any time with or without notice, and Cockaigne that I am applying to has

the same right. I understand that a pre-employment physical will not be required. However, Cockaigne reserves the right

to require a physical examination of all applicants within a specific work group once an offer of employment has been made.

Furthermore, Cockaigne reserves the right to a drug or alcohol test prior to employment, at any time during employment

and/or after any job related accident to the extent permitted by law. I understand that Cockaigne may investigate my

driving and criminal record and that an investigative consumer report may be prepared whereby information is obtained through

personal interviews with my neighbors, friends and others with whom I am acquainted. I understand that I have the right to make

a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this

investigation. I further understand that Cockaigne may contact my previous employers and I authorize those employers to

disclose to Cockaigne all records pertinent to my employment with them. I release all parties from liability for any

damages that may result from furnishing or discussing the requested information. I hereby state that all of the information that I

provided on this application and in any interview is true and accurate. I understand that if I am employed and any such

information is later found to be false in any respect, I may be dismissed. I also understand that this application does not create a

contract of employment nor does it guarantee employment for any period of time. If employed I understand that I have been

hired at the will of the employer and my employment may be terminated at any time, with or without cause and without notice.

Applicants Signature: _____________________________ Date: ________/_____/20_____