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):

    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):

    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):

    # of Milking Units per Side (required):

    Milking System Make & Model (required):

    Type of Floor Scraping System (required):

PRACTICES:

    Fore strip Teats (required):

    Wiping Material (required):

    Milkers Inject Cows (required):

    Treated Cows in Separate Group (required):

    Treated Cows Mixed in Various Groups (required):

    Milkers Chase Groups (required):

    Pre and Post Dip Same Solution (required):

    ID System (please describe identification system for treated cows, e.g. red band means treated cow) (required):

HOUSING:

    Distance from Worksite (required):

    Smoke Detectors in All Bedrooms (required):

    Heat, Electricity, Clean Water (required):

    Carbon Monoxide Detector (1 Central) (required):

    First Aid Kit (required):

    Fire Extinguisher (required):

    Telephone (required):

    Dishes, Glasses, Cooking Utensils (required):

    Kitchen Table & Chairs (required):

    Vacuum Cleaner, Broom, Cleaning Tools (required):

    Stove & Refrigerator (required):

    Dressers, Beds w/Linens & Blankets, Bath Towels (required):

    Living Room Couch or Chair (required):

    TV with Satellite or Cable (Spanish Channels) (required):

REFERENCES:

    Veterinarian or Breeder (required):

    Relationship:

    Phone (required):

    Reference 2 (required):

    Relationship:

    Phone (required):

    Reference 3 (required):

    Relationship:

    Phone (required):

Additional Information: