Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Vehicle Licences

Learners

Restricted

Full

Truck

Forklift

Referee #1

Name

First Name

Last Name

Referee #2

Name

First Name

Last Name

Covid 19 Vaccinations *

Are you up to date with your Covid 19 Vaccinations?

Yes I am fully vaccinated (both shots)

No I have only had 1 shot

No I am unvaccinated

Drug and alcohol testing

Random drug and alcohol testing may take place at Crozier Farm (especially for those operating vehicles/machinery), will you be willing to take a test?

Yes

No

Preferred Role

Are you applying for a specific role? Please select from the options.

Packing work (Lynchris Packing)

Farm work (Crozier Farm)

Up for anything

Health Declaration

Do you declare that you have provided true and complete answers in regard to your past and present health and you have not withheld any relevant information concerning this matter? Any information given, known to be untrue may exclude you from employment or may be grounds for dismissal following your appointment. This record will remain confidential to Crozier Farm.

Yes

No

Application Declaration

Do you declare that the information you have given on this application form is true and correct and that no information has been withheld that is relevant to this application?

Yes

No

Contacting Referees

Do you give permission for the referees listed above to be contacted to gain information regarding your work history or as a character reference?

Yes

No