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NORTH JERSEY DISTRIGr WATER SUPPLY COMMISSION
We consider applIcants for all posItions wHhout regard to race , color , religion, sex, national origin ,
age. marotal or veteran status, the presence of a non-job-related medIcal condition or handicap,
or any other legally protected status
APPLICATION FOR EMPLOYMENT
(PLEASE PRINT)
)1 The STATE of NEW JERSEY
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Each questIOn should be fully and accurately answered. No action can be taken on this application unti l all questions have been answered ,
Use blank paper if you do not have enough room on this application blank, PLEASE PRINT, except lor signature on back of Application . Atl
information you give on this application Will be held in strict confidence.
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Date 01 Application
Position(s) App lied For
How Did You Learn About Us?
_ _ _ Advertisement
Employment Agency
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___ Friend
Walk-In
_ _
Other _ _ _ _ _ _ _ __ _ _ __ __
Relative
First Name
Last Name
Middle Name
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Address
Number
Street
City
State
Telephone Number(s)
ZIp Code
Social Securrty Number
Length 01 reSidence rn New Jersey ___ _
Who Is to be notified In case 01 an emergency?
Name
Relationship
Address
Telephone No ,
If you are under 18 years 01 age, can you provide required proof of your eligibility to work?
__ Yes
No
Have you ever liled' an application wi th us belore?
__ Yes
__ No
If Yes, give date _ _ __
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Are you cu rrently employed?
__ Yes
_
May we contact your present employer?
__ Yes
__ No
Are you prevented Irom lavilu lly becomll1g employed In this country because of Visa or Immigratron Status?
__ Yes
_ _ No
Have you ever worked under another name or were you educated under another name
(necessary to verily applicant's qualifications)
_ _ Yes
__ No
Are you currently on " lay-off' status and subject to reca ll?
Yes
_ _ No
Can you I ravel if a job requires it?
Yes
_
,No
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On what date would you be available for work?
Are you available to work: _ _ Full TIme
Temporary
Part Time
Have you been convicted of a felony within the last 7 yea rs?
If Yes , please explain
_ _
Shitt Work
_~ Yes
No
No
High
School
Elementary
School
Graduate
Professional
Undergraduate
College/University
SchoOi Name and
Location
Years Completed
4 5 6 7 8
9
10
11
234
12
234
Diploma/Degree
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Describe Course
of Study
Describe any
specialized tra ining .
apprenticeship, skills
and extracurricular
activities
Describe any honors
you have received
------------------------------------
State any additional
information you feel
may be helpful to us
In considering your
application
Indicate any foreign languages you can speak, read and/or write if relevant to the position you are apptying for :
FLUENT
SPEAK
FAIR
GOOD
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READ
WRITE
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List profeSSional , trade , business or civic licenses and/or offices held . You may exclude memberships which would reveal sex. race . rel igion.
national Origin , age or handicap or other protected status:
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Have you ever had any job-related training In the United States military?
__ Yes
No
Yes
No
If Yes , please describe
Are you physi cally or otherwise unable to perform the duties of the job for which you are applYing?
Give name, address and telephone number of three references who are not relaled to you and are not prev ious employers.
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4.
SIan With your present or lasl Job Include any job-related United States military service assignments and volunteer activities. You may ex­
clude organizations which Indicate race . color. religion , gender, national origin, handicap or olher protected status .
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Employer
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Dates Employed
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WORK PERFORMED
Address
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Hourly Rate/SalarLy __________
Telephone Number(s)
Starting
Job Title
Reason for Leaving
Supervisor
Final
Dales Employed
Employer
From
WORK PERFORMED
To
Address
Hourly Rale/Salary
Telephone Number(s)
Starting
Final
Supervisor
Job Title
Reason tor Leaving
Dates Employed
Employer
From
WORKPERFOAM~
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To
Address
Hourly Rate/Salary
Telephone Number(s)
Sla~_~
Final
Supervisor
Job Title
Reason for Leaving
Qat ~s
Employer
Employ.':d __
From
WORK PERFORMED
To
Address
Hou~
Telephone Number(s)
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Rat e/Salary
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Job Title
Final
Supervisor
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Reason for LeaVing
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If you need additional space , please contmue on a separate sheet of paper.
SPECIAL SKILLS AND QUAUFICATIONS
Summa rize special job-related skil ls and qualifications acquired from employment or other experi ence
Have you previously been employed by North Jersey District Water Supply Commission?
_
Yes
_
No
If yes , stale period of employment and reason lor termmat ion __
I cerlily Ihat answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in th is application for employment as may be necessary In arriving at an employment
decision .
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This application for employment shall be considered active for a period of time nol 10 exceed 45 days . Any applicanl wishing to be considered
for employment beyond this time period shoul d Inqu ire as to whether or not applications are being accepted at that l ime .
I hereby understand and acknowledge that , unless otherwise defined by applicable law, any employment relationship with th is organization is
of an "al will" nature, wh ich means that the Employee may resign at any time and the Employer may discharge the Employee at any time ,
with or without cause . It is further understood that this "at wi ll " employment realtlonshlp may not be changed by any written document or by
conduct unless such cha nge is specifica lly acknowledged in writing by the Board 01 Commissioners of the North Jersey District Water Supply
Commission .
In the event of employment , I understand that fa lse or misleading information given In my application or intervlew(s) may result In d ischarge .
understand , also, that I am required to abide by all rules and regu lations 01 the employer .
Signature of App licant
Date
FOR PERSONNEL DEPARTMENT USE ON LY
Arr ange Intervi ew
_
Yes
No
Remarks
Interv iewer
Dale
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Employed
__ Yes
No
Date 01 Employm ent
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Hourly Rate/Salary
Name an d Title
Department
Date
NOTE S
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To : All Appli cants f or Empl oyment to the
North Jersey District Water Supp ly Co mmissi on
RE LEASE OF RECORDS AUTH ORIZATION
By sign ing be low, I authorize the North Jersey District W ater
Supply Co mmiss ion (the " Com mi ssion") to ve rify all inf ormation
provi ded by me an d unde rstand that t he Co mmission may p ro cure or
have prepa red a consu me r or investigative con s umer repo rt to verify,
amo ng other th ings, pri or empl oyment or military record , e d ucation,
ch aracter, gene ral reputation, personal characteristi cs , criminal rec ord
an d m ode of living. I un dersta nd that upon written request to the
Comm iss ion, I will be informe d of whether an investig ative consumer
report was req uested and gi "e n full information as to the nature and
scope of this investigation.
By s ig ning bel ow, I fu rther authorize and request that all of my
prese nt and f o rmer employe rs, educational institution s and those
ind iv i d uals I have listed as perso nal referen ces furni s h info rmation
about my em ploym ent reco rd, including a statem ent of the re ason f o r
th e t erminati on of my employ ment, work performan ce , abiliti es , and
ot her qualities perti nent to my qualifications for employment, and
here by re lease t hem from any and all liability f o r furni s hing the
re q ueste d information.
Si g nature Date