WHEELER RIDGE-MARICOPA wATER STORAGE DISTRICT

Employment Application

 

Applicant Information

Last Name

 

First

 

M.I.

Date

 

Street Address

 

Apartment/Unit #

 

City

 

State

 

ZIP

 

Phone

 

E-mail Address

 

Date Available:

 

Social Security No.         NOT APPLICABLE

Desired Salary:      (per hour)        

 

Position Applied for:

                                                                 

Drivers License No:   _____________________                                       

Class ______

State ______

Is drivers license  restricted, suspended, or revoked?

YES 

NO 

Have you ever worked for this company?

YES 

NO  

If so, when?

 

 

Name and relationship of friend/relative employed by the District:

 

 

 

 

 

Are you a citizen of the United States?

YES 

NO 

If no, are you authorized to work in the U.S.?

YES 

NO 

Do you have any physical conditions requiring accommodation?

YES 

NO 

If yes, explain

 

Have you ever been convicted of a felony?

YES 

NO 

If yes, explain

 

 

Education

High School

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

College

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

Business or Trade School

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

 

LIST ATTACHED CERTIFICATES OF TRAINING AND CURRENT DMV:

 

 

DESCRIBE MECHANICAL EXPERIENCE:

 

 

 

 

 

References

Please list three references who are not related to you or previous employers.

 

 

 

 

Reference 1

 

 

 

Full Name

 

Relationship

 

Company

 

Phone

(           )

Address

 

 

 

 

 

Reference 2

 

 

 

Full Name

 

Relationship

 

Company

 

Phone

(           )

Address

 

 

 

 

 

Reference 3

 

 

 

Full Name

 

Relationship

 

Company

 

Phone

(           )

Address

 

 

 

 

Previous Employment

Company

 

Phone

(           )

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

 

 

 

 

Company

 

Phone

(         )

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

 

 

 

 

Company

 

Phone

(         )

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

Are you currently on “lay off” status and subject to recall?    

YES 

NO 

 

 

Military Service

Branch

 

From

 

To

 

Rank at Discharge

 

Type of Discharge

 

If other than honorable, explain

 

 

Disclaimer and Signature—Read carefully before signing

I hereby certify that all statements made in this applications are true and complete to the best of my knowledge.   I authorize investigation of all disclosures contained in this application.  I understand that any misstatement or omission of material facts in this application will cause forfeiture on my part of all rights if employed by the District.  I further agree to submit to a pre-employment medical examination, a pre employment drug screen by the District toxicologist (if applicable), and a current California DMV Report. 

Signature

 

Date