LOST HILLS WATER DISTRICT

APPLICATION FOR EMPLOYMENT

We are an “at-will” equal opportunity employer, dedicated to a policy of non-discrimination in  employment on any basis including race,    color, age, sex, religion, disability, medical condition, national origin, or marital status.  Offers of  employment may be contingent on applicant passing a job-related physical examination, drug screen and/or a skills and agility test.

 

Position Sought:  ________________________________________________________________________

 

Name_____________________________________________________________ Date________________

Address__________________________________ City___________________ State________ Zip_______

Home Phone ____________________ Office Phone __________________  Other Phone_______________

 

Email Address: ______________________________ Social Security#_____________________________

 

       On what date would you be available for work? ____________________ Desired Wage/Salary $________

Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restriction? [    ] Yes [    ] No
Have you ever been convicted of a felony? [    ] Yes [    ] No     If yes, please describe circumstances: __________
_______________________________________________________________________________________

Have you ever been involuntarily terminated or asked to resign from any position of employment? [    ] Yes [    ] No
If yes, please describe circumstances: ________________________________________________________________________
_______________________________________________________________________________________________________
If selected for employment, are you willing to submit to a pre-employment drug screening test?       [    ] Yes [    ] No

 

EDUCATION
School Name	Location	Years Attended	Degree Received	Major

Other training, certifications, or licenses held: _________________________________________________________________
____________________________________________________________________________________________________

List other information pertinent to the employment you are seeking: ________________________________________________
____________________________________________________________________________________________________

 

 

 

EMPLOYMENT

(Most Recent First.)

 

1.  Employer_____________________________________________ Job Title______________________________________

Dates Employed______________ Prior Position Held within Company (if any):  ____________________________________

Address_________________________________ City_______________________________ State________ Zip___________

Phone____________________ Job Title_______________________ Supervisor_____________________________________

Starting Salary________________________________    Ending Salary_______________________________

Duties Performed _______________________________________________________________________________________

Reason for Leaving _____________________________________________________________________________________

 

2.  Employer_____________________________________________ Job Title_______________________________________

Dates Employed______________ Prior Position Held within Company (if any):  _____________________________________

Address_________________________________ City_______________________________ State________ Zip____________

Phone____________________ Job Title_______________________ Supervisor______________________________________

Starting Salary________________________________    Ending Salary_______________________________

Duties Performed ________________________________________________________________________________________

Reason for Leaving ______________________________________________________________________________________

 

 

 

3.  Employer_____________________________________________ Job Title________________________________________

Dates Employed______________ Prior Position Held within Company (if any):  ______________________________________

Address_________________________________ City_______________________________ State________ Zip_____________

Phone____________________ Job Title_______________________ Supervisor______________________________________

Starting Salary________________________________    Ending Salary_______________________________

Duties Performed ________________________________________________________________________________________

Reason for Leaving _______________________________________________________________________________________

 

REFERENCES
Name	Address	Phone	Position	Years Acquainted

 

ACKNOWLEDGMENT AND AUTHORIZATION

 

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.  It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application

or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

 

 

_________________________________________        ___________________

Signature of Applicant                                                                Date