Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Race

African-American

Hispanic/Latino

Asian

Native American

Caucasian/White

Pacific Islander

Current Age

Social Security Number

Parent/Guardian Name

This person is my

Place of Employment and Title

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Other Parent/Guardian Name

This person is my

Place of Employment and Title

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Current School Name

School Phone Number

(###)

###

####

Grade Point Average

Current Grade Level

Name of teacher who knows you well

Name of person writing your reference

This person is my:

How did you find out about us?

Why do you want to be a member of Mill Village Farms? What interests you about Mill Village Farms?

Tell about a time when you helped a friend, family member, or someone in your community. What was the situation and what did you do? How did you feel about it?

What do you think will be your biggest challenge working at Mill Village Farms?

What would you like to achieve this year? How can Mill Village Farms help you do that? What do you want to get out of this job?

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Programs