Your Name (required): Your Email (required): APS Representative Name: Subject: DAIRY EMPLOYEE REQUEST BUSINESS INFORMATION: Business Name (required): Employer Federal ID# (required): Business Contact Name (required): Employer Entity Type (required): IndividualCorporationPartnershipLLC E-mail Address (required): Re-enter E-mail Address (required): Phone Number (required): Mobile Number: Fax Number: Physical Address (required): Mailing Address (if different): WORKER INFORMATION: # of Entry-Level Dairy Employees Needed (required): Can Offer 60+ hrs. of work per week (required): ---YesNo Date When Employees Will Be Needed (required): Hourly Wage (required): Milking Shift for New Employees (required): # of Milking Groups (required): MILK COOP INFO: Milk Coop Company Name (required): Milk Coop Contact Person (required): Milk Coop Contact Phone Number (required): Milk Coop Member Number (required): Names of Authorized Signees (required): WORKER'S COMP INFO: Insurance Carrier Name (required): Policy # (required): Expiration Date (required): Contact Info (required): HERD INFORMATION: # of Cows Milked per Day (required): Pounds per Cow per Day (required): Milking Frequency (required): EQUIPMENT: Milking Parlor Type (required): ---HerringboneParallelTie StallOther # of Milking Units per Side (required): Milking System Make & Model (required): Type of Floor Scraping System (required): ---Alley ScraperSkidsteerOther PRACTICES: Fore strip Teats (required): ---YesNo Wiping Material (required): ---PaperCloth Milkers Inject Cows (required): ---YesNo Treated Cows in Separate Group (required): ---YesNo Treated Cows Mixed in Various Groups (required): ---YesNo Milkers Chase Groups (required): ---YesNo Pre and Post Dip Same Solution (required): ---YesNo ID System (please describe identification system for treated cows, e.g. red band means treated cow) (required): HOUSING: Distance from Worksite (required): ---On-site< 1 mile> 1 mile Smoke Detectors in All Bedrooms (required): ---YesNo Heat, Electricity, Clean Water (required): ---YesNo Carbon Monoxide Detector (1 Central) (required): ---YesNo First Aid Kit (required): ---YesNo Fire Extinguisher (required): ---YesNo Telephone (required): ---YesNo Dishes, Glasses, Cooking Utensils (required): ---YesNo Kitchen Table & Chairs (required): ---YesNo Vacuum Cleaner, Broom, Cleaning Tools (required): ---YesNo Stove & Refrigerator (required): ---YesNo Dressers, Beds w/Linens & Blankets, Bath Towels (required): ---YesNo Living Room Couch or Chair (required): ---YesNo High Speed Internet (required): ---YesNo REFERENCES: Veterinarian or Breeder (required): Relationship: Phone (required): Reference 2 (required): Relationship: Phone (required): Reference 3 (required): Relationship: Phone (required): Additional Information: Please leave this field empty.