Employment Application - Beckley Water Company

Name*

First Last

Date of Birth*

Social Security Number*

Address*

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

Home Phone*

Cell Phone

Email*

Are you legally allowed to work within the United States?*

Yes
No

Do you have a valid Driver's License?*

Yes
No

License Number*

Date Issued

Expiration Date

Issuing State

Do you hold a drivers license with a CDL Endorsement?

Yes
No

Do you hold a drivers license with a Class A Endorsement?

Yes
No

Do you hold a drivers license with a Class B Endorsement?

Yes
No

Do you hold a drivers license with a Class C Endorsement?

Yes
No

Do you hold a drivers license with a Class D Endorsement?

Yes
No

Do you presently have traffic violation points against your driver license?

Yes
No

How many?

Do you suffer from habitual drunkeness or from narcotics addiction or dependence?*

Yes
No

Are you of good moral character?

Yes
No

Have you ever been convicted of a felony in this state or any other state or territory?*

Yes
No

Please explain what kind and any circumstances you wish to share.

Position Applied For:*

Are you available full time?*

Yes
No

Are you available for rotating shifts?*

Yes
No

Are you available part time?*

Yes
No

What days and hours are you available for work?*

Start Date*

Have you ever applied before?

Yes
No

When?

Have you ever served in the U.S. Military or Naval

Yes
No

Rank

Education

Education*

High School
Partial College
College
Other

Name of High School

Year Completed

Diploma*

Name of College

Year Completed

Diploma

Other Education

Year Completed

Diploma or Certificate

Employment History

(Start with your present/most recent job.)

1st Company Name:*

1st Company Address:*

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

1st Company Phone:*

1st Supervisor's Name:*

First Last

1st Company Date Hired:*

1st Company Date Left:*

Weekly Pay Rate:*

(List starting and ending Pay Rate)

Description of Job Duties:*

Job Title:*

Reason for Leaving:*

2nd Company's Name:

2nd Company's Address:

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

2nd Company's Phone:

2nd Supervisor's Name:

First Last

Employed To - From:

Weekly Pay Rate:

(List starting and ending pay rates)

Describe Job Duties:

Job Title:

Reason for Leaving:

Do you have any other special training, certifications, or professional licenses?

Personal References

1st Reference Name:*

1st Reference Address:*

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

1st Reference Phone:*

2nd Reference Name:*

2nd Reference Address:*

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

2nd Reference Phone:*

Confirmation

I understand that in processing my application with Beckley Water Company, an investigative consumer report may be conducted to obtain and verify information relating to my past activities and background. Information may include, but not limited to; employment history, education, criminal records, credit history, motor vehicle records, personal references, and any data provided on this application, or during the interview process.

If currently employed: My current employer may be contacted:

Yes, you may contact my current employer.
No, you may not contact my current employer.

I authorize the appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. I further understand and waive my right of privacy in this investigation and release and hold harmless Beckley Water Company and its agents, from any liability. An investigative consumer report may be generated summarizing this information. I have a right under the "Fair Credit Reporting Act" to obtain a copy of this report. I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, and I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may be cause for rejection or termination of my employment or application.

Confirmation*

I do swear/confirm that the above answers given are true and correct. I understand responses given are subject to verification by Beckley Water Company.

Education

Employment History

Personal References

Confirmation

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