Mail To:

WOLLAM GARDENS

5167 Jeffersonton Road
Jeffersonton, Va. 22724
Tel. (540) 937-3222
Email bob@wollamgardens.com

NAME: DATE:

PRESENT ADDRESS: PHONE:

PERMANENT ADDRESS: PHONE:

SOCIAL SECURITY #:

PRESENT EMPLOYMENT OR SCHOOL STATUS:

EXPECTED FIRST DAY READY FOR WORK:

EXPECTED LAST DAY OF WORK:

ANY KNOWN VACATION DAYS?

PHYSICAL CONDITION - DESCRIBE:

DO YOU HAVE HEALTH INSURANCE?

ARE YOU ALLERGIC TO ANYTHING?

PREVIOUS JOBS: NAME, TEL.#, AND CONTACT

FARM RELATED EXPERIENCE:

DRIVING EXPERIENCE AND RECORD: (ATTACH COPY OF DRIVER'S LICENSE):

GROUP HOUSE EXPERIENCE:

REFERENCES: (Names & tel. of two employers):

PLEASE TELL US HOW YOU FOUND OUT ABOUT THIS INTERN PROGRAM?