Employment Application

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Position for which you are applying*

Expected Rate of Pay*

Are you currently employed?*

Yes
No

May we contact your employer?*

Yes
No

Do you have any relatives employed by Jefferson County PUD?*

Yes
No

Please Identify the Employees

Can you, with or without reasonable accommodation, perform the essential functions of the job for which you are applying?*

Yes
No

Do you have any commitments that might affect your work availability or employment with us?*

Yes
No

If so, please identify:

Are you eligible to work in the United States?*

Yes
No

Have you served in the United States military?*

Yes
No

Do you have a valid driver's license?*

Yes
No

If yes, identify state issued

Do you have a valid commercial driver's license?*

Yes
No

If yes, identify state issued Please also identify class and endorsements on CDL

How did you hear about the this position?

Check all that apply

Other sources of job information

Education and Certificates

High School Info

Name	City/State	Yrs. Completed	Major/Degree(s)

College or University

Name	City/State	Yrs. Completed	Major/Degree(s)

Trade School

Name	City/State	Yrs. Completed	Major/Degree(s)

Other

Name	City/State	Yrs. Completed	Major/Degree(s)

Do you have a current flagging card?*

Yes
No

Do you have a current first aid/CPR card?*

Yes
No

Please list any other licenses or certifications:

Information Needed For Office Positions Only

What business machines can you operate?

What computer applications are you familiar with?

How would you describe your level of computer skills?

Employment History

Previous Employer Information 1*

Employer	Address:	Your Title	Supervisor	Phone Number	Employment start date:	Employment end date:	Reason for leaving:

Duties*

Previous Employer Information 2*

Employer	Address:	Your Title	Supervisor	Phone Number	Employment start date:	Employment end date:	Reason for leaving:

Duties*

Previous Employer Information 3*

Employer	Address:	Your Title	Supervisor	Phone Number	Employment start date:	Employment end date:	Reason for leaving:

Duties*

Reference 1*

No relatives, please.

Name	Phone #	Relationship	Job Title	Company

Reference 2*

Name	Phone	Relationship	Job Title	Company

Reference 3*

Name	Phone No.	Relationship	Job Title	Company

Resume*

Please upload here. Word or PDF preferred.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 20 MB, Max. files: 3.

Cover Letter*

Please upload here. Word or PDF preferred.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 20 MB, Max. files: 3.

Applicant Statement and Signature*

I certify that I have read, fully understand and accept all terms of the following Application Statement.

RESIDENCE REQUIREMENT
All Jefferson County Public Utility District employees are required to reside within the District’s service territory. The residency requirement must be met within 6 months of hire date.
EQUAL OPPORTUNITY
Jefferson County PUD #1 is an equal opportunity employer, and employment opportunities will not be limited because of age, race, color, religion, gender, sexual orientation, gender identity, pregnancy, marital status, nationality, genetic information, physical or mental disability, military or veteran status or any other basis prohibited by law. Jefferson County PUD affirmatively seeks to employ and advance qualified Vietnam veterans and disabled veterans. Hiring, promotions, layoffs, discharge, rates of pay, training and other employment activities will be consistent with this Equal Opportunity Statement. Jefferson County PUD #1 abides by the principals of the Age Discrimination in Employment Act (ADEA) and Americans with Disabilities Act (ADA) and does not unlawfully discriminate on the basis of age or disability.
DRUG POLICY
It is the policy of the PUD#1 of Jefferson County to maintain a drug free workplace. Employees who are observed in possession of, or using controlled substances (drugs) will be terminated and may have criminal charges filed against them. If you are affected by or become an abuser of drugs or alcohol you may ask for help from your supervisor.
AGREEMENT
I certify that all information I have provided in order to apply for and secure work with the PUD#1 of Jefferson County is true, complete and correct.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (a) cancel further consideration of this application, or (b) immediately discharge me from the employer's service whenever it is discovered.
This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the General Manager or his/her designee.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard and provide appropriate documents within 72 hours of employment.
RELEASE
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I consent to the release of my DOL driver's abstract, defendant case history, and court documents available from law enforcement and court agencies, whether in paper or electronic format.

Public Utility District No. 1 of Jefferson County is subject to the Washington Public Records Act, RCW 42.56. Therefore, this email and its attachments, if any, may be disclosed as a public record.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

Signature*

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