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Application For Employment
 

 Personal Information

Name (first, middle, last):

Address:
City: State: Zip:
Telephone:
E-mail:
Are you 18 years or older?    Yes  No
 
Are you eligible to be lawfully employed in the United States?
Yes No
(proof of citizenship or immigration status will be required upon employment.)
 
Have you ever been convicted of a felony offense? Yes No
 
   If yes, please list details including date's) of conviction:
  
   (A positive response will not necessarily disqualify you from employment)
Employment Desired
 
Position:
 
 
Month  Day   Year
Date you can start:
 
 
Minimum salary desired:
 
 
  Full Time Temporary ( 6 months) Summer (3 months)
 
Are you employed now?  Yes  No
 
May we contact your current employer?  Yes  No
Driving Information


License #:		                                

Month  Day   Year

 

Expiration Date:
 
 
Do you have a valid state of Maine driver's license? Yes  No
             Class  A B C
 
Do you have knowledge in the operation of:
 6 Wheel Dump Truck  10 Wheel Dump Truck Backhoe 
  Front End Loader Paving Breaker Power Hand Tools
 
Has your license ever been revoked? Yes  No
 
May we contact Motor Vehicles Division to obtain your driving record?
Yes  No
 
Federal regulations CRF 49 Part 40.25 requires we ask if you have ever tested positive for a pre-employment drug or alcohol testing and not seen a SAP (substance abuse professional)?Yes No

Employment History

List present or last employer first, going back 10 years.  Please include dates (to and from), company name, address & phone, salary, position, and reason for leaving.

Company Name Dates of Employment Address & Phone Position Salary Reason
for
leaving


Military or Service: Yes No      Rank:
 
Schools & special training:
 
Present membership in National Guard or Reserve?
If applying for work that requires clerical functions
 
Are you keyboard proficient? Yes No   Words per minute:
Training in Microsoft Office software:
Word Excel           Powerpoint        Access       Other
                                                                         
                                                                         		 
Basic Skill:
Advance Skill:

Education
 
School Name & Address Course of Study Did you graduate? Diploma
Elementary
High Yes No
College Yes No
Other Yes No
Other Yes No

Special Skills, Training, Licenses, or Languages:
References
(give names of three persons NOT RELATED to you, whom you've known in a work capacity for at least one year. Include their name, address, phone number, business, and number of years of acquaintance)
1.
2.
3.
Physical Record
Do you have the full physical, mental, emotional and medical ability to do the job for which you have applied, with or without a reasonable accommodation?
                       Yes No

Please describe in detail how you will do the job for which you have applied, with or without a reasonable accommodation:
Read carefully before signing. 
I fully release and hold harmless the District and any references the District contacts, including previous and present employers, schools, persons, and investigating bureaus relating to any and all information exchanged to arrive at an employment decision.

BY CHECKING THIS BOX I SIGN THIS APPLICATION AND AGREE THE FACTS SET FORTH IN MY APPLICATION FOR EMPLOYMENT ARE TRUE AND COMPLETE.  I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENTS MADE WILL RESULT IN DISQUALIFICATION FROM EMPLOYMENT, OR IF HIRED, IMMEDIATE DISCHARGE.  I FURTHER UNDERSTAND THAT THIS APPLICATION IS NOT AND IS NOT INTENDED TO BE A CONTRACT OF EMPLOYMENT.

Name:    Date:

 


 
Portland Water District - 225 Douglass Street - Portland, Maine 04104-3553
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