Employment Application

Size: px

Start display at page:

Download "Employment Application"

Amy McKinney
6 years ago
Views:

Employment Application Northcentral Mississippi Electric Power Association places great emphasis on customer service, teamwork, problem solving, and innovation.

1 Employment Application Northcentral Mississippi Electric Power Association places great emphasis on customer service, teamwork, problem solving, and innovation. We look for people who exemplify these qualities and are willing to work hard for our membership. Northcentral Mississippi Electric Power Association is an equal opportunity employer. Applicant Name Today s Date

2 Personal Information (Please Print Clearly) Last Name First Name Middle Name Street Address City State Zip Code Previous address if less than 5 years at current address Home Phone Fax Work Phone I understand that upon employment, proof of legal right to work in the United States and completion of I-9 form will be required. Are you eligible to work for any United States employer at this time? Yes No If you are under 18 years of age, do you have a work permit? Yes No Have you ever been convicted of a felony? Yes No If yes explain Do you have a valid driver s license? Yes No License # Expires Do you have a valid Commercial Driver s License (CDL)? Yes No License # Expires Can you travel if the position requires travel? Yes No If you have ever worked under or earned degrees under another name, please list below: Last Name First Name Middle Name Position Desired Position Applied for How did you learn of this vacancy? Salary Desired (Annual) $ Date Available Are you able to perform the essential functions of this position? Yes No If no, what accommodation would make it possible for you to perform this job? Have you previously been employed by Northcentral Mississippi EPA or another electric cooperatives? Yes No If yes, indicate position, department, and dates: Do you have a relative on the board of directors or currently employed at Northcentral Mississippi EPA? Yes No If Yes, who? Northcentral Mississippi Electric Power Association is an equal opportunity employer and recruits, advertises, employs, promotes, transfers, disciplines, and discharges without regard to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, or veteran status.

3 Education and Training Indicate Last Level of Education Completed High School College or University Graduate School Type of Education Name and Location ( City, State, Country) GPA Did you graduate? Major and Minor Degree Earned Professional certifications and licenses (such as CPA, NASD series 6) Computer skills (software programs, hardware, operating systems) Other skills or experience that are pertinent to the job applied for Employment History (Please Print Clearly) MUST BE COMPLETED EVEN IF ATTACHING YOUR RESUME. List your last three employers with the most recent first. If you are currently employed, may we contact your employer? Yes No Previous Employer Dates Employed From To Starting Salary Ending Salary Contact s Phone Number Address Supervisor s Name Supervisor s Job Title Your Job Title Your Duties Reason for leaving

4 Previous Employer Dates Employed From To Starting Salary Ending Salary Contact s Phone Number Address Supervisor s Name Supervisor s Job Title Your Job Title Your Duties Reason for leaving Previous Employer: Dates Employed From To Starting Salary Ending Salary Contact s Phone Number Address Supervisor s Name Supervisor s Job Title Your Job Title Your Duties Reason for leaving Professional References (Please list only references that we may contact at this time) Name Title Company Phone Number Home Work Home Work Home Affidavit Nonbinding Application and Interview Process: I understand that this application will be reviewed, but nothing in this application or any other documents or in the employment evaluation process shall be construed as either an offer or contract of employment or an obligation on the part of Northcentral Mississippi Electric Power Association to provide any benefit to me. Employment-At-Will: I understand that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either Northcentral Mississippi Electric Power Association or myself. I hereby declare that my statements on this application and on my resume or documents provided by me to Northcentral Mississippi Electric Power Association are true and correct to the best of my knowledge. I acknowledge and agree that providing any false information may result in a decision not to hire me, or if hired, may result in the termination of my employment. I also authorize investigation of these statements. This investigation may include employment history, reasons for leaving previous employers, criminal record, credit record, driving record, social security number investigation, and degree/certificate verification. I understand that if offered employment, I will be required to take a physical examination and that such examination will include a blood or urine test to determine the presence or use of alcohol or controlled substances. I hereby release Northcentral Mississippi Electric Power Association from all liability for any damages resulting from the information obtained. This application shall be considered active for a period of time not to exceed 180 days. APPLICANT S SIGNATURE Work

5 Invitation to Self-Identify This company is subject to Executive Order 11246, as amended, which requires Federal contractors to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. We are therefore requesting information about race and gender in order to comply with government reporting requirements and in order to ensure equal employment opportunity. Submission of this information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Federal affirmative action regulations. Name: Date: Position: [ ] MALE [ ] FEMALE [ ] I CHOOSE NOT TO SELF-IDENTIFY [ ] WHITE (not Hispanic or Latino) [ ] BLACK or AFRICAN AMERICAN (not Hispanic or Latino) [ ] HISPANIC OR LATINO [ ] ASIAN (not Hispanic or Latino) [ ] AMERICAN INDIAN/ALASKA NATIVE (not Hispanic or Latino) [ ] NATIVE HAWAIIAN or PACIFIC ISLANDER (not Hispanic or Latino) [ ] TWO or MORE RACES (not Hispanic or Latino) [ ] I CHOOSE NOT TO SELF-IDENTIFY This company is also subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment veterans in the following classifications: A disabled veteran is one of the following: o a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or o a person who was discharged or released from active duty because of a service-connected disability. A recently separated veteran means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An Armed forces service medal veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. [ ] I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE [ ] I AM NOT A PROTECTED VETERAN

Application For Employment

Application For Employment We consider applicants for all positions without regard to race, color, religion, creed, gender, genetics, national origin, age, disability, marital or veteran status, sexual