Application for Employment

Handy Sanitary District

Handy Sanitary District is an Equal Opportunity Employer and this application is designed to provide Handy Sanitary District with substantial information to insure equal employment opportunities for all applicants. All questions are intended only for the utilization in consideration of employment, without regard to race, color, religion, sex, national origin, age, marital or veteran status, disability, or any other legally protected status.

Position Applied For: ________________________________ Date:________________

Who referred you to us? How did you hear about this position? ____________________

_______________________________________________________________________

Personal Information:

Name:__________________________________________________________________

First Middle Last

Address:________________________________________________________________

_______________________________________________________________________

Phone #’s:_______________________________________________________________

Home Other(s)

Social Security #_____________________ Driver’s License State & #_______________

In case of emergency, notify:________________________________________________

Name Phone #

_______________________________________________________________________

Address

Have you ever been employed with Handy Sanitary District before? ____ Yes____ No

If yes, reason for separation: ______________________________________________

______________________________________________________________________

Are you above the minimum working age of 16? ____Yes ____ No

If you are under the age of 16, can you furnish a work permit? _____ Yes _____ No

Will you be prepared to produce proof of employment eligibility at the time of employment, in accordance with the Immigration Reform and Control Act of 1986?_____ Yes ____ No

Will you be prepared to allow Handy Sanitary District, at the time of employment, to check your credit? ____ Yes ____ No

Have you ever been convicted of an offense against the law other than a minor traffic violation? _______ Yes _______ No If yes, please explain fully on an additional sheet of paper. (A conviction does not mean you can not be hired. The offense and how recently you were convicted will be evaluated in relation to the job which you are applying.)

Can you perform the essential functions of the job for which you have applied with or without reasonable accommodation? ___ Yes ____ No

Educational Information:

Circle the highest grade/school year completed: 9 10 11 12 13 14 15 16 17 18

Did you graduate from high school or pass the equivalency test? ____H/S ____ GED

	Name and Location	Dates Attended	Years Completed	Did you graduate?	Diploma or Degree Received and Year
High School
College or University
Other

List all fields of work for which you are licensed, registered, or certified, providing dates and sources of issuance:____________________________________________________

________________________________________________________________________

________________________________________________________________________

List any academic achievements/extracurricular activities relative to the position applied for:____________________________________________________________________

_______________________________________________________________________

List any additional knowledge, skills, or qualifications relative to the position applied for:__________________________________________________________________

_____________________________________________________________________

Employment Experience:

List present or most recent employer first. Be sure to include military service, if any.

May we contact your current employer? ______ Yes ______ No

Employer:____________________________________ Phone #:____________________

Address:________________________________________________________________

Position:____________________ Supervisor: _________________________________

Primary Responsibilities:___________________________________________________

_______________________________________________________________________

Reason for leaving:_______________________________________________________

Dates employed:_______________ Starting Salary___________ Final Salary_________

Employer:____________________________________ Phone #:____________________

Address:________________________________________________________________

Position:____________________ Supervisor: _________________________________

Primary Responsibilities:___________________________________________________

_______________________________________________________________________

Reason for leaving:_______________________________________________________

Dates employed:_______________ Starting Salary___________ Final Salary_________

Employer:____________________________________ Phone #:____________________

Address:________________________________________________________________

Position:____________________ Supervisor: _________________________________

Primary Responsibilities:___________________________________________________

_______________________________________________________________________

Reason for leaving:_______________________________________________________

Dates employed:_______________ Starting Salary___________ Final Salary_________

Employer:____________________________________ Phone #:____________________

Address:________________________________________________________________

Position:____________________ Supervisor: _________________________________

Primary Responsibilities:___________________________________________________

_______________________________________________________________________

Reason for leaving:_______________________________________________________

Dates employed:_______________ Starting Salary___________ Final Salary_________

Employer:____________________________________ Phone #:____________________

Address:________________________________________________________________

Position:____________________ Supervisor: _________________________________

Primary Responsibilities:___________________________________________________

_______________________________________________________________________

Reason for leaving:_______________________________________________________

Dates employed:_______________ Starting Salary___________ Final Salary_________

References:

Please provide the information for three persons, excluding previous employers or relatives:

Name_____________________________ Phone #_________________

Name ____________________________ Phone #_________________

Name_____________________________ Phone #_________________

Agreement:

I certify that the statements made in this application are correct and complete to the best of my knowledge and belief. I understand that if I am employed, false or misleading information on this application shall be considered sufficient cause for termination. If I am offered a position of employment with Handy Sanitary District, I authorize Handy Sanitary District to conduct a background check, which will provide the following obtained information: verification of social security number, past addresses, education, professional licenses, past employment, as well as credit history, driving records, criminal and civil records searches, and reference checks. I hereby authorize my previous employers, personal references listed, educational institutions, and other persons/organizations listed on this application for employment to provide Handy Sanitary District with any information requested unless otherwise noted on this application regarding present employer. In the event that Handy Sanitary District is unable to verify any reference stated on this application, it is my responsibility to furnish the necessary documentation.

Signature_________________________________ Date________________