Answer each question fully and accurately. Please print or type. Date ________________

Last Name: First Name: Middle name:
Street: City: State: Zip:
Home Phone: Work Phone:		Social Security #:
Position applied for:	Salary Requirement:
Date available for employment: _____________ Are you seeking: Regular Full-time Part-time Temporary Summer only

How did you hear about this position? Please specify _____________________________________________________________________

Do you have any relatives currently on staff? YES NO

If yes, give name(s) and relationship(s)  _____________________________            

Are you 18 years of age or older? YES NO

Have you filed an application here before? YES NO If yes, when? ______________

Are you on a lay-off and subject to recall? YES NO

Have you ever been convicted of anything other than a minor traffic violation? YES NO

If yes, please give the date, place and nature of the charge of which you were convicted. (A conviction will not necessarily disqualify you from employment.)  ________________________________________________________________________       

____________________________________________________________________________________ 

If hired, can you furnish proof that you are eligible to work in the United States? (Employment is contingent upon satisfactory proof of eligibility to work in the United States.) YES NO

Have you worked or attended school under any other name? YES NO

If yes, give name(s)  ______________________________

May we check with your present employer for a reference? YES NO

EDUCATION

Apprentice, business or vocational school:

School and Location

Major

Diploma/Degree

Graduated (yes/no)

EMPLOYMENT EXPERIENCE

please complete this section even if you plan to attach a resume. List your last three employers, beginning with the most recent. Account for all periods of time including military service and periods of unemployment.

Name and Address of Employer	Dates Employed	Duties Performed
________________________________  _______________________________ _______________________________ Telephone: _____________________	MO/YR From: ___________ To: _____________	____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
	Hourly rate/salary: Start: ___________ End: ____________
Job Title:   ____________________________                   Status: Full-time Part-time Temporary Supervisor’s Name: ____________________________________ Reason for leaving: _____________________________________
Name and Address of Employer	Dates Employed	Duties Performed
________________________________  _______________________________ _______________________________ Telephone: _____________________	MO/YR From: ___________ To: _____________	____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
	Hourly rate/salary: Start: ___________ End: ____________
Job Title:   ____________________________                   Status: Full-time Part-time Temporary Supervisor’s Name: ____________________________________ Reason for leaving: _____________________________________
Name and Address of Employer	Dates Employed	Duties Performed
________________________________  _______________________________ _______________________________ Telephone: _____________________	MO/YR From: ___________ To: _____________	____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
	Hourly rate/salary: Start: ___________ End: ____________
Job Title:   ____________________________                   Status: Full-time Part-time Temporary Supervisor’s Name: ____________________________________ Reason for leaving: _____________________________________

SKILLS AND QUALIFICATIONS

Some positions require certifications. Please list any certification(s) in which you have acquired:

Certification(s) _________________________________________________________________________________________

Please summarize skills or additional training and qualifications acquired from employment, military service or other experience.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

REFERENCES

List those familiar with your job performance and personal characteristics who have known you a MINIMUM OF ONE YEAR. DO NOT LIST RELATIVES.

Note: A job offer may be contingent upon acceptable references.

Name	Years Known	Relationship	Organization	City, State	Home & Business Phone Number
					H B
					H B
					H B
					H B

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this application and any attachments is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment, or, if I am hired, may result in my dismissal from employment if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and that my employment may be terminated at any time, with or without cause and with or without notice. I understand that no employee or representative of Water & Wastewater Services, LLC, other than the Owner, Kelly Wynn, has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the foregoing.

I have read, understand and consent by my signature to these statements.

________________________________

SIGNATURE

________________________________

DATE

PLEASE SUBMIT COMPLETED APPLICATION VIA MAIL, FAX, OR E-MAIL