Public Water Supply District No. 3 EMPLOYMENT APPLICATION

Date of Birth

Date

Full Name

Last NameFirst NameMiddle Name

Maiden Name

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permanent Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PHONE NO.

Format: (000) 000-0000.

Are you 18 years or older?

Are you prevented from lawfully becoming employed in this country because of VISA or Immigration status?

Position

Date You Can Start

Date

Salary Desired

Are you currently employed?

If so, May we contact with your present employer?

Have you ever applied to PWSD No. 3 before?

If so, When did you previously apply?

Were you referred by anyone? If so, Please list the name of individual.

HIGH SCHOOL: Name and Location of School

HIGH SCHOOL: Number of Years Completed

HIGH SCHOOL: Did you Graduate?

HIGH SCHOOL: What subjects did you study?

COLLEGE: Name and Location of School

COLLEGE: Number of Years Completed

COLLEGE: Did you Graduate?

COLLEGE: What subjects did you study?

BUSINESS / TRADE SCHOOL: Name and Location of School

BUSINESS / TRADE SCHOOL: Number of Years Completed

BUSINESS / TRADE SCHOOL: Did you Graduate?

BUSINESS / TRADE SCHOOL: What subjects did you study?

PROFESSIONAL SCHOOL: Name and Location of School

PROFESSIONAL TRADE SCHOOL: Number of Years Completed

PROFESSIONAL SCHOOL: Did you Graduate?

PROFESSIONAL SCHOOL: What subjects did you study?

Have you ever been convicted of a crime?

If yes, Please indicate number of conviction(s)

If yes, Please explain nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Do you have reliable transportation to work?

Do you have a driver's license?

If yes, what type of driver's license?

Driver's License Number

State of Issue for Driver's License

Driver's License Expiration Date

Date

Have you had any accidents during the past 3 years?

If yes, How many?

Have you had any moving violations during the past 3 years?

If yes, How many?

Do you have any computer skills/knowledge?

List any other skills

Have you ever been in the armed forces?

Are you currently a member of the national guard?

Specialty

Date Entered

Date

Discharge Date

Date

Name of Reference

Position

Company

Address

Street Address

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Name of Reference

Position

Company

Address

Street Address

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

An application form sometimes makes it difficult for an individual to adequately summarize a complete background Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying

Name of employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Format: (000) 000-0000.

Employment Start Date

Date

Employment End Date

Date

Ending Pay / Salary

Name of Last Supervisor

Your Last Job Title

Reason for Leaving (please be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Name of employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Format: (000) 000-0000.

Employment Start Date

Date

Employment End Date

Date

Ending Pay / Salary

Name of Last Supervisor

Your Last Job Title

Reason for Leaving (please be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Name of employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Format: (000) 000-0000.

Employment Start Date

Date

Employment End Date

Date

Ending Pay / Salary

Name of last supervisor

Your last job title

Reason for Leaving (please be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Name of employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Format: (000) 000-0000.

Employment Start Date

Date

Employment End Date

Date

Ending Pay / Salary

Name of last supervisor

Your last job title

Reason for Leaving (please be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

May we contact your current employer?

Did you complete this application yourself?

If not, who did?

PLEASE READ CAREFULLY APPLICATION FORM WAIVER

In exchange for the consideration of my job application by PWSD #3 (hereinafter called "the Company"), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of PWSD #3, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Office Manager of the Company. Both the undersigned and PWSD #3 may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. Iauthorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of applicant

Date

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Public Water Supply District No. 3 EMPLOYMENT APPLICATION

(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

EMPLOYMENT DESIRED

EDUCATION

MILITARY

REFERENCES

WORK EXPERIENCE