Application For Employment

PERSONAL

Date*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Position Desired

Wage Required

Referred by

Available for shift work?

Yes
No

Available for call-in?

Yes
No

Are you legally eligible for employment in the United States?*

Yes
No

Date Available

During the past ten years, have you ever been convicted of a crime other than minor traffic offense?*

Yes
No

If yes, explain:

(A conviction will not necessarily automatically disqualify you from employment. )

Have you ever worked for this company before?*

Yes
No

If yes, which department?

Dates of Employment

EDUCATION

High School: Number of years completed:*

1
2
3
4

Diploma?

Yes
No

GED?

Yes
No

Name of High School

City/State

College and/or Vocational School: Number of years completed:

1
2
3
4

Name of School(s)

City/State

Major

Degrees Earned

Other Training or Degrees: Name of School (s)

City/State

Course

Certification

ADDITIONAL EXPERIENCE OR SKILLS

List any other experience, skills or other qualifications which you believe should be considered in evaluating your qualifications for employment, such as experience in operating heavy equipment, experience with electric motors or pumps, office and/or computer skills, military service

EMPLOYMENT

Start with your current or most recent position

May we contact your current employer?*

Yes
No

If any employment was under a different name, indicate name:

Name of Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Supervisor's Name

Dates of Employment

Position Held

Rate of Pay

Department

Describe duties:

Reason for leaving:

Name of Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Supervisor's Name

Dates of Employment

Position Held

Rate of Pay

Department

Describe duties:

Reason for leaving:

Name of Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Supervisor's Name

Dates of Employment

Position Held

Rate of Pay

Department

Describe duties:

Reason for leaving:

APPLICANT'S CERTIFICATION AND AGREEMENT

First Utility District is an equal opportunity employer and does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for First Utility District to hire me. If I am hired, I understand that either First Utility District or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of First Utility District has the authority to make any assurance to the contrary. I attest with my signature below that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize First Utility District to verify their accuracy and to obtain reference information on my work performance. I hereby release First Utility District from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Signature*

Date*

This application for employment is good for six (6) months only. Consideration for employment after six (6) months requires a new application.

About