Employment Application for Lozier's Box "R" Ranch

Please print this form, fill it out and mail to us. We look forward to hearing from you!

Please “PRINT” or “WRITE” legibly                                                      Date_________________________

Last Name_____________________________________ Phone_______/_________/___________

First Name____________________________________ Cell ________/_________/_____________

Middle Name _______________________________ E-Mail________________________________

Mailing Address____________________________________________________________________

Physical Address____________________________________________________________________

City __________________________________________State________________ Zip_____________

Permanent Address (If Different)_________________________________________________________

City __________________________________State _____________________Zip_________________

Social Security Number ___________________________Date of Birth________/____________/______

Your Date of Birth______________ Height________ Weight__________ Male / Female (Circle)

Marital Status____________________ Ages of Children ______________________________

Close friend or family member to contact in case of emergency

Name ______________________________________________________

Phone _____________________________________Cell____________________________________

Address ___________________________________________City__________________St__________

I would like to apply for a position as a _____________________________________________________

because I feel that I have the following essential qualifications and skills (Please list and describe in detail):

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Attach Resume and

(Include any comments you feel are relevant to your ability, personality and capabilities to perform in the position applied for, that will assist our personnel and management in determining if we have the right employment opportunity available for you.)

What other position (s) would you be willing to take?___________________________________________

I/am - would be available to work from ________________________to ___________________________

(Consideration will first be given to those who can complete the entire season).

EMPLOYMENT

Are you currently employed?_______

Employer__________________________________________________

Contact___________________________________________________

Phone __________________________

The reason I am pursuing this job or other employment (confidential)

__________________________________ _________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Three past employment references (names, addresses, contact information):

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Two personal references: (Name, Phone number and how long have you known or relationship)

____________________________________________________________________________________

_____________________________________________________________________________________

Wage at last job $___________________ hourly / monthly (Circle)?

Expected wage/month $_________________ w/board & room provided.

Drivers License#______________________ State______ Type_______ CDL License _____ No _____ Yes

List all vehicles you feel qualified or comfortable operating ________________________________________

_____________________________________________________________________________________

PHYSICAL RECORD

______ I drink occasionally (comment)______________________________________________________

______ I do not drink (comments) _________________________________________________________

______ I do smoke ______ I do not smoke.

I consider my health to be (circle one) Excellent / Good / Adequate for the position I am seeking.

______ I am ____ I am not taking medication for (condition)

____________________________________________________________________________________

Do you have any other health conditions we should be aware of?___________________________________

I hereby  authorize a statement from my physician, Dr.___________________________________________

Dr. Phone _____________________________________________

City & State___________________________________________

EDUCATION

I have completed_____________ years of school and graduated in _______________(date) I also received

specialized education in _______________________________________________________________

Degree received _______________________________________________________________

WORK AIDS

Do you have your own transportation?____________ Kind?____________ Do you have any items which you might wish to use in conjunction with your position or employment that you feel are beneficial? (i.e. tools, saddle etc.)

___________________________________________________________________________________

____________________________________________________________________________________

No Pets are allowed, unless specifically agreed to by Employer.

Please feel free to make any other comments (below) you feel may be pertinent: special certificates, memberships, clubs, special interests, recreation preferences etc.

Have you ever been convicted of a felony? _______if so, date-charge-penalty

____________________________________________________________________________________

Have you been convicted of a misdemeanor charge in the last five years?____________________________

Have you served in the military? __________if so, what branch________________, how long?___________

Do you hold a First Aid or EMT rating?_____________ If so, what? ________________________________

I authorize investigation of all statements contained on this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is at-will and for no definite period without contract, and may, regardless of the payment of wages and salary, be terminated at any time without notice, unless otherwise agreed to in writing.

Signature______________________________________________________________date________________

Please return with photo and/or resume' to:

Box "R" Ranch - P. O. Box 100 - Cora, Wyoming 82925
Phone: 307-367-4868 | Fax: 307-367-6260 | info@boxr.com

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