Employment Application Form

 

INSTRUCTIONS: It is important that you fill out all sections of this application completely and to the best of your ability. Your application will be used as part of the certification process and, therefore, should represent your best effort.

As an equal employment opportunity employer, the Authority assures you that your opportunity for employment will be based on your merit without regard to race, age, color, religion, sex or national origin.

 

*Mandatory Fields

 
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* indicates a required field

First Name *


Last Name *


Position Applied For *


Street Address 1 *


Street Address 2


City *


State


ZIP *


Telephone *


Email *


Lowest Acceptable Salary *


Are you legally eligible for employment in the United States? *

Are you available for full-time work? *

If no, what hours can you work?


When will you be available to begin work? *


What is the highest grade you have completed? (1-12)


Are you a high school graduate? *

Do you possess a high school equivalency certificate GED? *

Education 1 - Name & Address of College or School Attended


Education 1 - Major or Specialty


Education 1 - Types of Diploma, Degree, License, or Certificate Earned


Education 2 - Name & Address of College or School Attended


Education 2 - Major or Specialty


Education 2 - Types of Diploma, Degree, License, or Certificate Earned


Education 3 - Name & Address of College or School Attended


Education 3 - Major or Specialty


Education 3 - Types of Diploma, Degree, License, or Certificate Earned


Please list the kinds of office equipment or construction equipment you can operate


Do you have a valid driver's license? *

Branch of Service


Rank at Discharge


Date of Final Discharge

Select a date from the calendar.

Reserve Status


Describe your duties and any special training


May we contact your current supervisor? *

Previous Employer 1 - Employer Name *


Previous Employer 1 - Your Job Title *


Previous Employer 1 - Address *


Previous Employer 1 - Supervisor *


Previous Employer 1 - Supervisor's Title *


Previous Employer 1 - Telephone *


Previous Employer 1 - Employed From *


Previous Employer 1 - Employed To *


Previous Employer 1 - Starting Salary (or Hourly Rate) *


Previous Employer 1 - Ending Salary (or Hourly Rate) *


Previous Employer 1 - Describe your duties *


Previous Employer 1 - Reason for leaving *


Previous Employer 1 - Account for time between jobs


Previous Employer 2 - Employer Name


Previous Employer 2 - Your Job Title


Previous Employer 2 - Address


Previous Employer 2 - Supervisor


Previous Employer 2 - Supervisor's Title


Previous Employer 2 - Telephone


Previous Employer 2 - Employed From


Previous Employer 2 - Employed To


Previous Employer 2 - Starting Salary (or Hourly Rate)


Previous Employer 2 - Ending Salary (or Hourly Rate)


Previous Employer 2 - Describe your duties


Previous Employer 2 - Reason for leaving


Previous Employer 2 - Account for time between jobs


Previous Employer 3 - Employer Name


Previous Employer 3 - Your Job Title


Previous Employer 3 - Address


Previous Employer 3 - Supervisor


Previous Employer 3 - Supervisor's Title


Previous Employer 3 - Telephone


Previous Employer 3 - Employed From


Previous Employer 3 - Employed To


Previous Employer 3 - Starting Salary (or Hourly Rate)


Previous Employer 3 - Ending Salary (or Hourly Rate)


Previous Employer 3 - Describe your duties

Previous Employer 3 - Reason for leaving


Previous Employer 3 - Account for time between jobs


Have you been convicted of any violation(s) of the law (felony, misdemeanor, traffic)? Violations convicted as a juvenile do not need to be disclosed. *

If yes, describe in full:


References - State names of relatives and/or friends working for us or on our Board of Directors


Reference 1


Please provide the Name, City/State, Telephone, Job Title and Company of a reference not related to you who has knowledge of your qualifications.

Reference 2


Please provide the Name, City/State, Telephone, Job Title and Company of a reference not related to you who has knowledge of your qualifications.

Reference 3


Please provide the Name, City/State, Telephone, Job Title and Company of a reference not related to you who has knowledge of your qualifications.

Where did you hear about this position?


If you selected "Referral" or "Other" to the question above, please provide additional information here (Name, location, etc.)


Please copy and paste your resume into the box at right *


Please copy and paste your cover letter into the box at right


Signature *


By typing my name, I certify that the information supplied by me in this application is true to the best of my knowledge and belief. I understand that my misstatement of material facts will cause forefeiture of all my rights and to any employment or result in dismissal employment, if hired.

Date Signed *

Select a date from the calendar.

Attachments

 

Bedford Regional Water Authority
1723 Falling Creek Road • Bedford • VA 24523
540.586.7679

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