Handy Sanitary District Application for Employment

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: ______________________________________

Personal Information:

Name:__________________________________________________

First Middle Last

Address:_________________________________________________

________________________________________________________

Phone #’s:________________________________________________

Home Other(s)

Social Security #__________________________________________

In case of emergency, notify:_________________________________

Name

________________________________________________________

Phone # Address

Have you ever been employed with Handy Sanitary District before?

_____ Yes ______ No

If yes, reason for termination: ________________________________

________________________________________________________

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 school year completed: 1 2 3 4 5 6 7 8 9 10 11 12

Did you graduate from high school or pass the equivalency test?

____Yes ____ No

	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.

Employer:____________________ Phone #:____________________

Address:_________________________________________________

Position:____________________ Supervisor:___________________

Starting Salary________________ Final Salary__________________

Primary Responsibilities:____________________________________

________________________________________________________

Reason for leaving:_______________________________________

_______________________________________________________

Employer:____________________ Phone #:____________________

Address:_________________________________________________

Position:____________________ Supervisor:___________________

Starting Salary________________ Final Salary__________________

Primary Responsibilities:____________________________________

________________________________________________________

Reason for leaving:_______________________________________

_______________________________________________________

Employer:____________________ Phone #:____________________

Address:_________________________________________________

Position:____________________ Supervisor:___________________

Starting Salary________________ Final Salary__________________

Primary Responsibilities:____________________________________

________________________________________________________

Reason for leaving:_______________________________________

_______________________________________________________

Employer:____________________ Phone #:____________________

Address:_________________________________________________

Position:____________________ Supervisor:___________________

Starting Salary________________ Final Salary__________________

Primary Responsibilities:____________________________________

________________________________________________________

Reason for leaving:_______________________________________

_______________________________________________________

Employer:____________________ Phone #:____________________

Address:_________________________________________________

Position:____________________ Supervisor:___________________

Starting Salary________________ Final Salary__________________

Primary Responsibilities:____________________________________

________________________________________________________

Reason for leaving:_______________________________________

_______________________________________________________

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. I authorize Handy Sanitary District to conduct a background check so that a hiring decision may be made. 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. 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. If accepted for employment with Handy Sanitary District, I agree to abide by all of its policies and procedures. I understand that no representative of Handy Sanitary District has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement or assurances contrary to the foregoing, unless it is in writing and signed by an authorized company representative. If employed, I understand that I may terminate my employment at any time without notice or cause, and that Handy Sanitary District may terminate or modify my employment relationship at any time without prior notice or cause. In consideration of my employment, I agree to conform to the rules and regulations of Handy Sanitary District. If employed, I understand that my employment is for no definite period of time, and if terminated, Handy Sanitary District is liable only for wages earned as of the date of termination. I agree also to have my photograph taken for identification purposes.

Date________________ Signature______________________________