Application for Employment Application for Employment The Muncie Sanitary District, Indiana, does not discriminate on the basis of race, color, gender, sexual orientation, gender identity, national origin, age, religion, or disability, in employment or the provision of servicesPosition sought: First name:(Required) Last name:(Required) Middle initial: Former names(s): Address: Email:(Required) City/state/zip: Phone:(Required) Are you interested in: Full-time work? Part-time work? Seasonal? Are you at least 18 years of age? Yes No Date available to start work: EMPLOYMENT HISTORY AND WORK EXPERIENCEList all employment history and work experience during the previous five years, beginning with your current employer. Failure to include all past employment may be grounds for disqualification.If currently unemployed, check here Unemployed? and skip to Previous employer below.Current employer: Address: City/state/zip: Phone: Hire date: Job title: Supervisor: Title: Work phone: Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions, etc:Why do you want to leave?May we contact your current employer? Yes No If no, please explain why:Previous employer: Address: City/state/zip: Untitled Phone: Dates employed: Job title: Supervisor: Title: Work phone: Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions, etc:Reason for leaving:May we contact your current employer? Yes No If no, please explain why:Previous EmployerPrevious employer: Address: City/state/zip: Phone: Dates employed: Job title: Supervisor Title: Work phone: Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions, etc:Reason for leaving:May we contact your current employer? Yes No If no, please explain why:List and explain periods of unemployment in the past five years:From (date) to (date): Reason (unless caused by medical condition(s)):From (date) to (date): Reason (unless caused by medical condition(s)):EDUCATION AND TRAININGThis section is intended to give the employer information about education and training you have completed, and to describe your skills, knowledge and abilities to perform the duties of the position. College(s) or Trade Schools(s)Name: Dates attended (State date - End date) Address: City/state/zip: Degrees(s): Major/minor course(s) of study: Name: Dates attended (Start date - End date): Address: City/state/zip: Degrees(s): Major/minor course(s) of study: Activities, awards: (You may exclude any which indicate race, color, religion, gender, sexual orientation, gender identity, age national origin, or disability.)Seminars/workshops, special awards, articles you have published, other information that may be relevant to the position you are seeking:MILITARY HISTORY AND STATUSIf you have never served in the military on active duty, check here and skip to the next section. Never Served Military Branch | Dates of Service | Highest Rank Attained | Rank at SeparationType of Discharge: Citations/awards received: PROFESSIONAL OR SPECIALIZED TRAININGSpecialized training: Select: CDL Class A CDL Class B Select: Air Brake Endorsement Tanker Endorsement HAZMAT Endorsement State | Issued by | Date Issued | Expiration | Type | License#Professional/special license(s) or certificate(s)Have you had any license suspended, revoked or terminated? Yes No If yes, explain:PROFESSIONAL AFFILIATIONSList current or previous affiliations/organizations and related offices/positions. (You may exclude any which indicate race, color, religion, gender, sexual orientation, gender identity, age national origin, or disability.)Organization Name | Address | Phone | Offices/PositionsUse the following space to describe other training, education, skills, abilities, hobbies, volunteer work or other information that may be helpful in evaluating your application. (You may exclude any which indicate race, color, religion, gender, sexual orientation, gender identity, age national origin, or disability.)PERSONAL INFORMATIONDo you have any commitments which might interfere with or adversely affect your employment with us, such as a second job or school? Yes No If yes, please explain:Have you ever been convicted of a felony? (Note: A guilty plea to or conviction of a crime is not an automatic bar to employment; all circumstances will be considered) Yes No If yes, please explain:Do you have any criminal charges currently pending against you? (Note: A pending charge is not an automatic bar to employment; all circumstances will be considered) Yes No If yes, please explain:List three references who are not related to you and are not former employers or supervisors who we are authorized to contact:Untitled Reference 1:Name: Phone: Address: City/state/zip: Number of years known: Reference 2:Name: Phone: Address: City/state/zip: Number of years known: Reference 3:Name: Phone: Address: City/state/zip: Number of years known: List any former employers or other individuals/organization we are not authorized to contact: Are you currently required to register as a sex offender in this or any other jurisdication? Yes No If yes, please explain (including jurisdiction of registry):APPLICANT CERTIFICATIONRead each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by signing your initial at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initialing.I understand and accept that, if I am hired, I may be hired conditional on passing any medical and/ or psychological examination that the employer deems necessary to determine my ability to perform the essential functions of the position. I understand and accept that this may include drug, alcohol or substance abuse testing. I understand that it may be necessary for me to approve and sign any waivers necessary in order for the employer to obtain information from my current and former employers. I understand that it may be necessary for me to approve and sign any waivers necessary in order for the employer to obtain information from my current and former employers. I understand and accept that if any information in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that, if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded. I solemnly swear that all of the information furnished in this employment application is true, accurate and complete to the best of my knowledge. I authorize investigation of all statement contained in this application. I understand that my misrepresentations or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment. By submitting this document, I hereby agree that I shall execute the employer’s conditional and postemployment medical examination and drug testing consent requirements. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use, or alcohol abuse.Applicant signature:(Required) Date:(Required) CAPTCHA After submitting this form please take a moment to submit the Affirmation Action Survey.
