Jackson Utilities Job Application

Application for Employment

All applicants will be considered for employment without regard to race, religion, color, sex, national origin, marital or veteran status, medical condition or handicap, or any other status protected by law.

We are an Equal Opportunity Employer.

Your application will be considered active for 30 DAYS.

Date

MonthDayYear

Full Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Format: (000) 000-0000.

E-mail

Are you over 18 years of age?

Are you legally eligible for employment in the United States? (Verification is required)

Position Applying For:

Date available to start work:

MonthDayYear

Salary or Wage Desired:

Education

Rows	Course Study	Years Completed	Graduation Date
High School
College
Other

Are you employed at the present time?

Do you have a valid driver's license?

CDL:

State driver's license issued:

Have you ever been convicted of a crime or other legal judgements?

If YES, list convictions or judgements and other details: ( A conviction/judgement does not necessarily disqualify applicant).

Former Employment (Last three employers)

Company

Address

Reference ContactPhone Number

Job Description

(Duties, Skills, Equipment Used)

Dates of Employment Start

MonthDayYear

End

MonthDayYear

Salary and/or Wage

Reason for Leaving:

Company

Address

Reference ContactPhone Number

Job Description

(Duties, Skills, Equipment Used)

Dates of Employment Start

MonthDayYear

End

MonthDayYear

Salary and/or Wage

Reason for Leaving:

Company

Address

Reference ContactPhone Number

Job Description

(Duties, Skills, Equipment Used)

Dates of Employment Start

MonthDayYear

End

MonthDayYear

Salary and/or Wage

Reason for Leaving:

Special Skills, licenses, or other related experience:

References: Give the names of three persons not related to you, whom you have known at least one year.

Reference 1 Name

Address

Business (if applicable)Phone Number

Years Acquainted

Reference 2 Name

Address

Business (if applicable)Phone Number

Years Acquainted

Reference 3 Name

Address

Business (if applicable)Phone Number

Years Acquainted

Physical Record:

Do you have any physical limitations that preclude you from performing any work for which you are considered:

If yes, please describe limitations:

What can be done to accommodate your limitations?

Emergency Contact: In case of emergency please notify

Name

Address

Phone NumberRelationship

Name

Address

Phone NumberRelationship

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, false statements on this application shall be grounds for dismissal.

I authorize investigation of all statement contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release all parties from all liability for any damage that may result from the furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND CHECK THE BOXES AFTER EACH STATEMENT.

Only those applications with check boxes are considered valid.

1. If the company employs me, I will comply with all work related requirements set forth by the company.

2. I understand I will be given a drug test prior to hiring and I consent.

3. I certify that all answers to the questions in this application are the truth and complete to the best of my knowledge. Ommissions may be grounds for denial of employment or discharge if hired.

4. I understand that no manager or reprsentative of the company, other than in writing signed by the president of the company and by me has any authority to enter into an agreement of employment for any specified period of time or contrary to the above terms or alter the above employment conditions.

5. I hereby acknowledge that I have read and understand the above statements. I voluntarily give the Company permission to confirm by personal inquiry, or otherwise, information provided in this application. I release from all liability or responsibility this company and all persons providing information to the company about me.

Applicant Signature

Date

MonthDayYear