Kalamazoo Lake Sewer and Water Authority Employment Application Applicants may be tested for prohibited drugs and/or alcohol Step 1 of 4 25% Name *(Required) First Middle Last Maiden NameMaidenSocial Security NumberYou may submit SSN at time of interviewPresent Address *(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you lived at that address?Telephone *(Required)Email *(Required) Are you 18 years of age or older? Yes No Are you legally authorized to work in the United States? Yes No Have you ever been employed by the Kalamazoo Lake Sewer & Water Authority? Yes No Position Applied ForSalary DesiredHow many hours can you work weekly?Can you work holidays? Yes No Can you work weekends? Yes No Can you work nights? Yes No Can you work On-Call? Yes No Employment Desired: FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME Days/Hours Available to Work:No Pref.Thurs.Mon.Fri.Tues.Sat.Wed.Sun.Are you able to perform all of the essential functions of the job for which you are applying, with or without reasonable accommodation: Yes No Don't Know If you answered No or Don’t Know, please explain:When is the soonest you are available to work?Have you ever been discharged or forced to resign from a position? Yes No If yes, provide details.Have you ever been disciplined or discharged for absenteeism or tardiness? Yes No If yes, provide details. EDUCATION AND OTHER INFORMATIONHigh SchoolHigh School NameHigh School # of years completed or credits earnedHigh School Degree acquiredHigh School Complete mailing addressBusiness or Trade SchoolBusiness or Trade School NameBusiness or Trade School # of years completed or credits earnedBusiness or Trade School Degree acquiredBusiness or Trade School Complete mailing addressCollege/UniversityCollege/University NameCollege/University # of years completed or credits earnedCollege/University Degree acquiredCollege/University # of years completed or credits earnedProfessional SchoolProfessional School NameProfessional School Complete mailing addressProfessional School Degree acquiredProfessional School # of years completed or credits earnedMILITARY SERVICEHave you ever been enlisted in the U.S. Armed Forces? Yes No If yes, what is your present selective service classification?BACKGROUND INFORMATIONHave you ever been convicted of a crime? Yes No Are there any pending charges against you? Yes No If you answered yes to either of these questions, please provide the dates, type of conviction, and any other information that is be pertinent. The Kalamazoo Lake Sewer and Water Authority may conduct a criminal history check to determine the existence of any arrest resulting in a conviction.Do you have a driver’s license? Yes No What is your means of transportation to work?Driver’s License NumberState of IssuanceDriver’s License Type Operator Commercial Chauffeur Driver’s License Expiration DateHave you had any accidents during the past three years? Yes No How many?Have you had any moving violations during the past three years? Yes No How many?Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No If yes, provide details.Has any license, permit, or driving privilege ever been suspended or revoked? Yes No If yes, provide details. Professional Licenses and/or CertificatesList professional licenses and/or certificates, including kind of license, certificate number, State and yearOFFICE ABILITIESTyping Yes No WPMWord Yes No Excel Yes No Personal Computer Yes No Microsoft Yes No Mac Yes No Other SkillsPlease provide two references that we may contact other than relatives.Reference #1Reference #1 Name First Last Reference #1 PositionReference #1 CompanyReference #1 AddressReference #1 PhoneReference #1 Email Reference #2Reference #2 Name First Last Reference #2 PositionReference #2 CompanyReference #2 AddressReference #2 PhoneReference #2 Email An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the specific position for which you are applying. WORK EXPERIENCEPlease list your work experience for the past ten years beginning with your most recent job held. If you were self-employed, give firm name.Job OneJob One Name of EmployerJob One Name of Last SupervisorJob One Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job One Phone NumberJob One TitleJob One Employment Dates From MM slash DD slash YYYY Job One Employment Dates To MM slash DD slash YYYY Job One Salary StartJob One Salary FinishJob One Reason for LeavingJob One: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.Job TwoJob Two Name of EmployerJob Two Name of Last SupervisorJob Two Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Two Phone NumberJob Two TitleJob Two Employment Dates From MM slash DD slash YYYY Job Two Employment Dates To MM slash DD slash YYYY Job Two Salary StartJob Two Salary FinishJob Two Reason for LeavingJob Two: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.Job ThreeJob Three Name of EmployerJob Three Name of Last SupervisorJob Three Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Three Phone NumberJob Three TitleJob Three Employment Dates From MM slash DD slash YYYY Job Three Employment Dates To MM slash DD slash YYYY Job Three Salary StartJob Three Salary FinishJob Three Reason for LeavingJob Three: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.May we contact your present employer? Yes No Did you complete this application? Yes No If you did not complete this application, who did?Consent(Required) In exchange for the consideration of my job application by the Kalamazoo Lake Sewer and Water Authority (hereinafter called “KLSWA”), I agree that:Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other KLSWA practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Kalamazoo Lake Sewer and Water Authority; or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Manager or Board of the KLSWA. Both the undersigned and the Kalamazoo Lake Sewer and Water Authority may end the employment relationship at any time, without specified notice or reason. If employed, I understand that KLSWA may unilaterally change or revise their benefits, policies and procedures and such Changes may include reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give KLSWA permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release KLSWA from any liability as a result of such contract. I also understand that (1) KLSWA has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations and written examinations as issued by the State of Michigan and/or the federal government. I understand that, in connection with the routine processing of your employment application, KLSWA may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, KLSWA will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting ActSignature(Required)Date(Required) MM slash DD slash YYYY KLSWA is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, protected disability, and/or any other factor prohibited by federal and/or state law. NameThis field is for validation purposes and should be left unchanged. Δ
