H-2A Employment Application/Questionnaire
Email *
A. Employer Information
Employer:  K.W. Zellers & Son, Inc.
Case#
Address: 13494 Duquette Ave. NE, Hartville, OH 44632
Phone: (330) 877-9371
H-2A Contract Period: 6/5/2023 - 10/22/2023
B. Applicant Information
1. Full name *
First and last name
2. Address *
3. Phone number *
4. Email *
5. Are you over the age of 16? *
6. The Job Order is a multi-page document that details all the terms, conditions, and requirements of the job.
a. Have you been offered the opportunity to read the Job Order, or has the Job Order been read to you? *
b. If YES, at which State Workforce Agency (SWA) did you read the Job Order?
c. Name of SWA representative
7. Are you available and willing to work for the entire H-2A contract period of 6/10/2019 to 10/20/2019? *
8. Please note the following pay rates:  
Hourly Rate - $17.17 (not eligible for overtime pay)

If offered, would you accept the job with this rate of pay? *
9. The job is physically demanding and involves working outdoors for long periods of time in all types of weather (hot, cold, rain, snow).  Work involves repetitive movements, extensive walking, bending, and lifting heavy objects throughout the work day.
a. Do you understand the physical requirements of the job? *
b. Are you willing and physically able to perform the work? *
c. Do you understand that work involves little, if any, indoor work? *
d. Do you understand and agree that if you are not physically able to perform the work, the company may terminate your employment? *
10. If your permanent residence is outside normal commuting distance from the worksite(s), the company will offer you housing accomodations.
a. Is your permanent residence outside of normal commuting distance from the worksite(s) listed in the Job Order? *
b. If YES, do you understand that company housing accommodations will be shared by other workers, some of whom may be foreign workers?
Clear selection
11. The company provides daily transportation to and from the worksite(s) for all workers residing in company-provided housing.  If you are not eligible for company-provided housing, you must provide your own transportation.
a. Do you have transportation to and from the worksite(s) each day? *
b. If NO, how do you plan to get to the worksite(s) each day?
12. a. Have you previously applied for a job with the company? *
b. If YES, when?
13. a. Have you previously been employed by the company? *
b. If YES, when?
c. If YES, what is your reason for leaving employment?
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14. Do you understand all the requirements of the job as stated in the Job Order? *
15. If you are qualified and offered this job, would you accept the position? *
The company may test workers for drug use (controlled and prohibited substances) in accordance with the conditions and procedures stated in the Job Order.  You may not use, handle, or sell drugs at any time on company premises, including company-provided housing.
1. Do you agree to abide by the company's drug testing policy? *
2. Do you understand that refusal to abide by the company's drug testing policy is reason to deny an offer of employment? *
C. Prior Work Experience
1. Previous employer *
2. Employer address *
3. Employer phone
4. Supervisor
5. Dates of employment *
6. Reason for leaving *
7. Describe all work tasks/duties performed *
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