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Request
for Non-Agricultural Employees

Please read carefully:

  • For employers only. Looking for job applications? Click here.
  • All questions must be answered.
  • All fields are required to process your request.
  • Incomplete applications may delay processing.
  • If a question does not apply, write “N/A.”
  • Confidentiality: Agri-Placement Services, Inc. (APS) treats all information as strictly confidential and uses it only to provide services.
  • If you need a printable version, click here, choose the PDF option, fill it out, and email it to contact@agriplacement.com with Request for Non-Agricultural Employees as the subject line.
1

Employer & Business Information

2

Work, Equipment & Practices

3

Housing Information

4

References

Employer & Business Information

Please complete this section to provide details about your business structure and operations.

1

Employer & Business Information

Employer Information

APS Representative's Name *
Employer Federal ID # *
Employer Name *
Entity *
Employer Physical Address *
Employer Mailing Address (If same as physical address, enter “N/A”) *
Contact Person(s) *
Phone Number(s) *
Cell Number(s) *
Fax Number(s) (If not applicable, enter “N/A”) *
Email(s) *
Workers’ Comp Ins Carrier *
Policy #
Expiration Date *
WC Contact Person *
WC Contact Person Phone # *

Business Information

Banking Institution Name  *
Bank Contact Person *
Bank Contact Phone # *
Authorized Signers' Names *
I understand that automatic or electronic payment of monthly fees will be required *
1

Employer & Business Information

2

Work, Equipment & Practices

3

Housing Information

4

References

Work, Equipment & Practices

Please complete this section to describe the type of work, tools, equipment, and practices used in your operations.

2

Work, Equipment & Practices

Work Information

# of Entry Level Employees Needed *
Preferred Date of Need *
Work Shift for New Employee(s) *
Job Duration *
How Many Hours of Work per Week? *
Competitive Hourly Wage *
Can Offer Competitive Work Hours (60+ hours per week)? *
Business Description & Tasks *
Equipment Operation Skills Needed *
Please provide other information that could help us identify and train prospective employee(s) *
1

Employer & Business Information

2

Work, Equipment & Practices

3

Housing Information

4

References

Housing Information

Please complete this section to provide information about the housing you will offer to workers.

3

Housing Information

Housing Location *
Heat, Electricity, Clean Water *
Smoke Detectors (All Bedrooms) *
Carbon Monoxide Detector (1 Central) *
First Aid Kit *
A Fire Extinguisher *
Telephone (access to phone for 911 emergency) *
Stove, Refrigerator *
Dishes, Glasses, Cooking Utensils *
Vacuum Cleaner, Broom, Cleaning Tools *
Kitchen Table and Chairs *
Dressers, Beds w/Linens & Blankets; Bath Towels *
Living Room Couch or Chair *
High Speed Internet *
1

Employer & Business Information

2

Work, Equipment & Practices

3

Housing Information

4

References

References

Please provide three business references. At least one must be your veterinarian or breeder.

4

References

Reference #1

Name *
Relationship *
Phone *

Reference #2

Name *
Relationship *
Phone *

Reference #3

Name *
Relationship *
Phone *

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Contact Us

  • 510 Clinton Square, PMB 5010
Rochester, NY 14604
  • 315-986-4738 Office

    802-329-2217 Fax
  • contact@agriplacement.com

About Us

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