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Employment Application

Employment Application

Employment Application detail

Instructions:

Please complete all sections of this application to the best of your ability. Your application will be part of the certification process and should represent your best effort.

Step 1 of 14

General Information

The Bedford Regional Water Authority (BRWA) is an equal employment opportunity employer. BRWA policies afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, sexual orientation, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law. Accordingly, if reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Human Resources at hr@brwa.com or via phone at (540) 586-7679.

First Name(Required)

Last Name(Required)

Telephone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What position are you applying for?(Required)

How did you hear about this position?(Required)

Please share where you heard about this position.(Required)

Please list BRWA employee.(Required)

What is your desired annual salary?(Required)

Employment Information

Are you over 18 years old?(Required)

Yes

You may be required to provide work authorization.

Are you legally eligible for employment in the United States?(Required)

Yes

Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Also, you will need to provide documentation to that effect should you be employed. For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?

Are you available for full-time work?(Required)

Yes

Please share your availability.(Required)

Have you worked for the BRWA in the past?(Required)

Yes

Please list the position(s) and dates of employment.(Required)

Do you have any relatives currently employed at the BRWA?(Required)

Yes

Please list employee(s) name and position(s).(Required)

Do you have a valid driver's license?(Required)

Yes

Do you possess a CDL?(Required)

Yes

CDL License Information

Please share your license information. If the position for which you are applying requires operation of a motor vehicle, the BRWA will obtain your driving records from the Virginia Department of Motor Vehicles; if your license is from another State you will be required to provide same.

License information:(Required)

Endorsements Type / Class State / Province / Region

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below.

Expiration Date(Required)

Month

Day

Year

Have you held additional licenses over the past three years?(Required)

Yes

License information:(Required)

Endorsements Type / Class State / Province / Region

Expiration Date(Required)

Month

Day

Year

Have you held additional licenses over the past three years?(Required)

Yes

License information:(Required)

Endorsements Type / Class State / Province / Region

Expiration Date(Required)

Month

Day

Year

If you have held additional licenses over the past three years, please provide documentation via file upload at the end of this application.

• If the position for which you are applying requires operation of a motor vehicle, the BRWA will obtain your driving records from the Virginia Department of Motor Vehicles; if your license is from another State you will be required to provide same.

Driving Experience

Class of Equipment(Required)

Straight truck

Tractor & trailer

Tractor & two trailers

Tractor & tanker

Multiple

Other

Type of Equipment(Required)

Date From(Required)

Month

Day

Year

Date To(Required)

Month

Day

Year

Number of Miles (Total)(Required)

Type of Equipment(Required)

Date From(Required)

Month

Day

Year

Date To(Required)

Month

Day

Year

Number of Miles (Total)(Required)

Type of Equipment(Required)

Date From(Required)

Month

Day

Year

Date To(Required)

Month

Day

Year

Number of Miles (Total)(Required)

Type of Equipment(Required)

Date From(Required)

Month

Day

Year

Date To(Required)

Month

Day

Year

Number of Miles (Total)(Required)

Please elaborate:(Required)

Example:
1) Class of equipment; Type of Equipment; Date From; Date To; Number of Miles (Total)
2) Class of equipment; Type of Equipment; Date From; Date To; Number of Miles (Total)
…

Please elaborate:(Required)

Example:
1) Class of equipment; Type of Equipment; Date From; Date To; Number of Miles (Total)
2) Class of equipment; Type of Equipment; Date From; Date To; Number of Miles (Total)
…

Accident Record

Have you been in any accidents over the past three years?(Required)

Yes

Date of Accident(Required)

Month

Day

Year

Please list most recent first.

Describe the accident's nature:(Required)

Number of Fatalities(Required)

Number of Injuries(Required)

Chemical Spills(Required)

Yes

Have you been in any other accidents over the past three years?(Required)

Yes

Date of Accident(Required)

Month

Day

Year

Please list most recent first.

Describe the accident's nature:(Required)

Number of Fatalities(Required)

Number of Injuries(Required)

Chemical Spills(Required)

Yes

Have you been in any other accidents over the past three years?(Required)

Yes

Date of Accident(Required)

Month

Day

Year

Please list most recent first.

Describe the accident's nature:(Required)

Number of Fatalities(Required)

Number of Injuries(Required)

Chemical Spills(Required)

Yes

If you have been involved in additional accidents over the past three years, please provide documentation via file upload at the end of this application.

Traffic Convictions and Forfeitures

Please do not include parking violations.

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?(Required)

Yes

Please explain:(Required)

Has any license, permit, or privilege ever been suspended or revoked?(Required)

Yes

Please explain:(Required)

Have you had any traffic convictions and/or forfeitures over the past three years?(Required)

Yes

Date Convicted(Required)

Month

Day

Year

Please list most recent first.

Describe the violation's nature:(Required)

State of Violation(Required)

State / Province / Region

Penalty Received(Required)

Have you had any other traffic convictions and/or forfeitures over the past three years?(Required)

Yes

Date Convicted(Required)

Month

Day

Year

Please list most recent first.

Describe the violation's nature:(Required)

State of Violation(Required)

State / Province / Region

Penalty Received(Required)

Have you had any other traffic convictions and/or forfeitures over the past three years?(Required)

Yes

Date Convicted(Required)

Month

Day

Year

Please list most recent first.

Describe the violation's nature:(Required)

State of Violation(Required)

State / Province / Region

Penalty Received(Required)

If you have had more traffic convictions and/or forfeitures over the past three years, please provide documentation via file upload at the end of this application.

Residency Information

Please provide the past three years of residency:

Residency 1(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years at address:(Required)

Please enter a number from 0 to 100.

Have you resided any where else over the past three years?(Required)

Yes

Residency 2(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years at address:(Required)

Please enter a number from 0 to 100.

Have you resided any where else over the past three years?(Required)

Yes

Residency 3(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years at address:(Required)

Please enter a number from 0 to 100.

If you have resided in additional locations, please provide documentation via file upload at the end of this application.

Educational Information

Please indicate education or training which you believe qualifies you for the position you are seeking.

Are you a high school graduate?(Required)

Yes

High School Information(Required)

Name of High School City State / Province / Region ZIP / Postal Code Country

Do you possess a GED?(Required)

Yes

Did you attend college?(Required)

Yes

What is the highest degree that you have received?(Required)

Institution Information(Required)

Name of Institution Major / Minor / Specialty City State / Province / Region ZIP / Postal Code Country

Have you received multiple degrees?(Required)

Yes

Please list degrees:(Required)

List degree, focus, and corresponding institution / location.

Have you completed any special courses, seminars, certifications, licensing, and/or training, or belong to an organization related to the position for which you are applying?(Required)

Yes

Please describe in full:(Required)

You need not disclose membership in a professional organization that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry age, disability, marital status, veteran status or any other protected status.

Work History

Please indicate your employers over the past three years starting with the most recent.

Employer Information 1(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

Have you had any other employers over the past three years?(Required)

Yes

Employer Information 2(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

Have you had any other employers over the past three years?(Required)

Yes

Employer Information 3(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

If you have had more employers over the past three years, please provide documentation via file upload at the end of this application.

Work History

Please indicate your employers over the past ten years starting with the most recent.

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years).

Employer Information 1(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?(Required)

Yes

Was this position designated as a safety-sensitive function in an Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

Have you had any other employers over the past ten years?(Required)

Yes

Employer Information 2(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

Have you had any other employers over the past ten years?(Required)

Yes

Employer Information 3(Required)

Name of Employer Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

May we contact this employer?(Required)

Yes

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?(Required)

Yes

Please describe duties:(Required)

Hire Date(Required)

Month

Day

Year

Leave Date(Required)

Month

Day

Year

Please describe reason for leaving:(Required)

If you have had more employers over the past ten years, please provide documentation via file upload at the end of this application.

Military Service

Please indicate if you have served in the armed forces.

Have you served in the armed forces?(Required)

Yes

Branch of Service(Required)

Rank at Discharge(Required)

Discharge Date(Required)

Month

Day

Year

Reserve Status(Required)

Please describe duties and any special training:(Required)

References

List three people who are unrelated to you and who have agreed to provide references.

Reference 1(Required)

Name of Reference Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

Please describe how this person knows you:(Required)

Reference 2(Required)

Name of Reference Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

Please describe how this person knows you:(Required)

Reference 3(Required)

Name of Reference Title Phone

.(Required)

Email City / State / Province / Region ZIP / Postal Code Country

Please describe how this person knows you:(Required)

Additional Information

If you wish to provide additional information in order to evaluate your application for employment, please use the space below:

Untitled

Cover Letter

Accepted file types: pdf, doc, jpg, doc, Max. file size: 98 MB.

Resume(Required)

Accepted file types: pdf, doc, jpg, doc, Max. file size: 98 MB.

Miscellaneous

Max. file size: 98 MB.

Certification & Agreement

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Bedford Regional Water Authority. I hereby release any people or organizations listed in this application from all liability to inquiries and releasing information in connection with my application.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

First Name(Required)

Last Name(Required)

Signature(Required)

Date(Required)

Month

Day

Year

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