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This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be require prior to employment. After an offer of employment, and prior to reporting to work, you are required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

What category would you prefer? Full-Time Part-Time Temporary Labor Pool
For which schedule are you available? Weekdays Weekends Evenings Nights Overtime Shift Other

NOTE: Do not fill out any part of this section you believe is not work related

Yes No
Yes No        
Yes No
Yes No
Yes No
Yes No
Yes No

If so, please describe below. (In accordance with company policy this information will be reviewed for job relatedness and time since last conviction.)


PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.

Most recent employer
Yes No     |     Yes No
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Dates Employed    
Second most recent employer
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Dates Employed    
Third most recent employer
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Dates Employed    

Include only individuals familiar with your work ability. Do not include relatives

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SER CORPORATION Referral and Release of Information
Place a check in the following agricultural industries in which you or your spouse have worked within the past two years
Cash Grains Wheat Corn Soybean Sunflower

Field Crops Cotton Potato Alfalfa Hay

Vegetables Tomato Bean Broccoli Watermelon Cucumber Pea Lettuce Watermelon Market gardens

Fruits & Nuts Grape Pecan Berry farms Walnut Citrus Apple Pear Peach

Nurseries Bulb Flower Green house Bedding plants

Livestock Dairy Feedlot Hog Cattle Sheep and Goats Turkey Chicken Eggs Poultry hatcheries

Crop Services Plowing Fertilizer Application Aerial spraying Thinning of crops Detasseling Hoeing Irrigation Weed control

Crop Harvesting Hay mowing Custom harvesting

Crop Preparation Pellet mill Grain cleaning Grain grinding Grain fumigation Grain elevator

SER Corporation is a not-for-profit organization that assist seasonal farmworkers find full time employment through education and job training. If you qualify for our services, SER may be able to assist you in finding full time employment.

If you checked any of the lines above please fill out the release below. Thank you.

If it has been over two years and you would like for SER to contact you to check other options through which you may still qualify. Please write down the last date that you worked in agriculture and sign the release below and someone from SER will get in contact with you.


I authorize Paul Wertenberger Construction to release the information on this paper to SER - Rural Initiatives of Kansas and for SER to contact me for the purpose of training and employment assistance.


By clicking "Submit Application," I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.