Employment Form

HARRISONBURG-ROCKINGHAM

REGIONAL SEWER AUTHORITY

Application of Employment

Equal Opportunity Employer. It is the policy of HRRSA to base personnel administration on merit principals, including equitable compensation based on job classification; evaluation, selection, and promotion based on ability, knowledge, skills, and performance; and fair and equal treatment of all applicants and employees in all aspects of personnel management without regard to their race. creed, color, religion, nation origin, ancestry, political affiliation, disability, sex, gender, age or marital status.

Full Name*

First NameM.I. Last Name

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Area CodePhone Number

Alternate Phone

Area CodePhone Number

Email Address*

example@example.com

Date Available*

Date

Date Available to

Date

Desired Salary

Salary or hourly rate acceptable

Desired Salary

Amount in $

Position Applied for:

Name(s) of any of your friends or relatives that work for HRRSA:

Were you referred to HRRSA by an existing HRRSA employee?

YesNo

If so, by whom?

Are you eligible to work in the United States?

YesNo

Have you ever worked for HRRSA?

YesNo

If yes, when?

Shifts willing to accept:

Are you available for full-time work

YesNo

Will you work overtime if required?

YesNo

In accordance with § 2.2-2804 of the Code of Virginia as amended, if you are/were required to register for the Selective Service, have you done so?

YesNo

If no, state reason:

Have you ever been convicted of a felony?

YesNo

If yes, explain*

*A conviction will not necessarily disqualify the applicant from employment

Education

High School:

City/State:

From:

Date

To:

Date

Did you graduate?

YesNo

Diploma:

College:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

From:

Date

To:

Date

Did you graduate?

YesNo

Degree:

Other:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

From:

Date

To:

Date

Did you graduate?

YesNo

Degree:

References

Please list three professional references:

Full Name #1:

Relationship:

Company:

Phone:

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Full Name #2:

Relationship:

Company:

Phone:

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Full Name #3:

Relationship:

Company:

Phone:

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Licenses

Driver's License #:

Exp. Date:

Date

Do you currently have a Wastewater Operator’s License?

YesNo

If yes, please specify class:

Previous Employment

Please list three previous employers (if applicable):

Company #1:

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities:

From:

Date

To:

Date

Reason for Leaving:

May we contact your previous supervisor for a reference?

YesNo

Company 2:

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities:

From:

Date

To:

Date

Reason for Leaving:

May we contact your previous supervisor for a reference?

YesNo

Company 3:

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities:

From:

Date

To:

Date

Reason for Leaving:

May we contact your previous supervisor for a reference?

YesNo

Military Service

Branch:

From:

Date

To:

Date

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, may result in disqualification for consideration for employment or, if already employed, discipline up to and including discharge.
I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. However, I understand that this application may continue to be active throughout the duration of the hiring process for the specific position in which I have applied if that takes longer than 30 days.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. I also agree to comply with all rules and regulations as set forth in HRRSA policies or procedures. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

Signature*

Date:

Date