Job Application

APPLICANT INFORMATION

Last, First and Middle Name: Date of Application (m/d/yyyy):
Email Address*:

APPLICANT INFORMATION

Have you ever been educated or worked under a different name? If yes, please indicate: Home Address (Number, Street, City, State & Zip Code): Phone Number: Mailing Address (if Different from Home Address):

POSITION APPLIED FOR

Applications are filed according to the position applied for; therefore, be specific.

Name of Position: Date Available: Hours Preferred How were you referred to us?

Education - High School (or Equivalent)

High School or Equivalent (Select One): School Name and Full Address: Course of Study:

Business or Technical School

School Name and Full Address: From Date (m/d/yyyy): To Date (m/d/yyyy): Type of Degree Received / Course of Study:

Undergraduate College or University

School Name and Full Address: From Date (m/d/yyyy): To Date (m/d/yyyy): Type of Degree Received / Course of Study:

Graduate School

School Name and Full Address: From Date (m/d/yyyy): To Date (m/d/yyyy): Type of Degree Received / Course of Study:

Other Schooling

School Name and Full Address: From Date (m/d/yyyy): To Date (m/d/yyyy): Type of Degree Received / Course of Study:

License/Certificate Information

License or Certificate?: Yes No

List Licenses Held with Number and Expiration Date if Appropriate:

Military Service

US Armed Forces: Yes No

Branch of Government Military: Date of Entry (m/d/yyyy): Date of Discharge (m/d/yyyy): Rank:

Veterans' Preference

(Check the appropriate block if you are claiming veterans' preference. Documentation substantiating your claim must be furnished at the time of application). NOTE: Under Florida law, preference in appointment shall be given by the state first to those persons included in 1 and 2 below, and second to those persons included in 3 and 4 below. If an applicant claiming veterans' preference for a vacant position is not selected for the vacant position, he/she may file a complaint with the Division of Veterans' Affairs, P.O. Box 1436, St. Petersburg, FL 33731. A complaint must be filed within 21 days of the applicant receiving notice of the hiring decision made by the employing agency or at any time notice is given.

A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement, or pension under public laws administered by the U.S. Veteran's Administration and the Department of Defense.

The spouse of a veteran who cannot qualify for employment because of a total and permanent disability, or the spouse of a veteran missing in action, captured, or forcibly detained by a foreign power

A veteran of any war who has served on active duty for 181 consecutive days or more, or who has served 180 consecutive days or more since January 31, 1955, and who was honorably discharged from the United States of America if any part of such active duty was performed during a war time era, excluding active duty for training

The unremarried widow of a veteran who died of service connected disability

Veteran's Preference - Have you claimed and been employed using veteran's preference since October 1, 1987? (If yes, include name of employer below).

US Government Employment

US Government Employee: Yes No

Branch of Government: From (m/d/yyyy): To (m/d/yyyy): Government Title:

Additional Training and Qualifications

Please list any experience, training, qualifications, or special skills that you think make you especially suited for work with this company or in this position.

Please list any experience, training, qualifications, or special skills that you think make you especially suited for work with this company or in this position.: If you did not graduate, why did you leave school or college?:

Courses and Training

List any courses or training programs you completed which will aid us in evaluating your qualifications for the position you are seeking. (Example: if applying for a administrative position, note training in Word programs, typing,calculator, or other computer programs.) Regardless of position, please include any computer programs you are familiar with. Be sure to include Course, School or Course Sponsor, Course Content and Grade

Course #1: Course #2: Course #3: Course #4:

Employment History - Current Employer

List below all places of employment or your whereabouts during the past FIVE years and all other significant employment prior to the past FIVE years. Include self-employment, military service, summer, and part-time jobs. If you worked for one employer on more than one occasion use a separate space below for each period. If unemployed, list residence and dates when unemployed. (Use additional sheet of paper if required.)

Current Employer - Salary / Job Title and Duties: Current Employer - Full Address / Telephone Number: Current Employer - End Date: Current Employer - To Date (m/d/yyyy): Current Employer - Supervisor's Name: Current Employer - Reason for Leaving?: Current Employer - Still in Business?: Yes No

Current Employer - May we contact this employer?: Yes No

Employment History - Former Employer #1

List below all places of employment or your whereabouts during the past FIVE years and all other significant employment prior to the past FIVE years. Include self-employment, military service, summer, and part-time jobs. If you worked for one employer on more than one occasion use a separate space below for each period. If unemployed, list residence and dates when unemployed.

Former Employer #1 - Salary / Job Title and Duties: Former Employer #1 - Full Address / Telephone Number: Former Employer #1 - Beginning Date: Former Employer #1 - End Date (m/d/yyyy): Former Employer #1 - Supervisor's Name: Former Employer #1 - Reason for Leaving?: Former Employer #1 - Still in Business?: Yes No

Former Employer #1 - May we contact this employer?: Yes No

Employment History - Former Employer #2

List below all places of employment or your whereabouts during the past FIVE years and all other significant employment prior to the past FIVE years. Include self-employment, military service, summer, and part-time jobs. If you worked for one employer on more than one occasion use a separate space below for each period. If unemployed, list residence and dates when unemployed.

Former Employer #2 - Salary / Job Title and Duties: Former Employer #2 - Full Address / Telephone Number: Former Employer #2 - Beginning Date: Former Employer #2 - End Date (m/d/yyyy): Former Employer #2 - Supervisor's Name: Former Employer #2 - Reason for Leaving?: Former Employer #2 - Still in Business?: Yes No

Former Employer #2 - May we contact this employer?: Yes No

Work Authorization

Are you at least 18 years of age?:
Yes No

Are you authorized to work in the United States?:
Yes No

Can you supply proof of such authorization?:
Yes No

Have you made any application at the District within the last six months?:
Yes No

Have you ever been convicted of, had adjudication withheld, or plead nolo contendere (no contest) or guilty to, a violation of any federal, state, county, or municipal laws?:
Yes No

If yes, please list the date and place of the offense, charge, and disposition. Include any convictions as the result of court-martial while in the military service. Do not include arrests without conviction or motor vehicle violations for which the only penalty imposed was a fine of $300 or less. (The existence of a criminal record does not constitute an automatic bar to employment.) Have you been arrested for any crime which has not yet been adjudicated?:
Yes No

If yes, please state the circumstances and current status of each arrest. A record of arrest will not be factored into the employment decision:

FOR DRIVER APPLICANTS ONLY

List all driver licenses held (include state, license type e.g. chauffeur ,operator and restrictions): How many years have you driven commercially?: Has any license been suspended or revoked? If yes, please include when, why, for how long and in what state(s) below: How many accidents have you ever been in, regardless of severity?: Please list the last three accidents below. Please include date, city/state and brief description of the accident.: List all traffic violations, other than parking, for which you have ever been cited. Please include date of violation, crime/infraction/other, name of court, court location, date of conviction and dispensation/fine): Indicate any safe driving awards you have received:

Professional References

List three references who can attest to your prior employment and work experience. Please include names, where you worked together, daytime phone number and years known.

References:

Professional Resume

Please Upload your Professional Resume (Maximum file size: 3MB)

PLEASE READ BEFORE SIGNING

If you have any questions regarding the following statements, please ask before signing.

Lake Apopka Natural Gas District (‘the District”) does not discriminate in hiring or employment on the basis of race, color, religion, sex, sexual orientation, national origin, age, disability, gender identity, genetic information, marital status or status within any other protected group. No questions on this application are intended to secure information to be used for such discrimination. (Initial below) I hereby certify that the answers and statements given by me in this application are correct and without consequential omissions of any kind. I agree that a false statement or omission may result in the withdrawal of any employment offer or dismissal from employment resulting in this application. (Initial below) I understand that all statements made by me in connection with my application for employment may be verified. I authorize all persons and the District and their agents to release any and all records and information pertaining to my employment history, police record, education background, military service, or personal reputation and hereby release and indemnify all parties from liability for damage and agree to hold them harmless for providing this information. (Initial below) I understand that the use of narcotics and alcohol is strictly prohibited at the District. Since an employee of the District is subject to blood tests or urinalysis screening for illegal drug use in accordance with the Department of Transportation, Pipeline Safety Regulations, Code of Federal Regulations, Title 49 C.F.R., Part 199, and since the District has adopted a program in compliance with the federal policy, if employed I agree to be bound by and comply with the federal law and the program of the District. (Initial below) I understand that if I become employed by the District my employment and compensation are for no definite period and, regardless of the time and manner of payment of my wages, salary or other benefits, my employment and compensation can be terminated at any time, with or without cause and with or without notice at either the option of the company or myself. Should this application result in my employment, it should not be construed to imply the existence of an employment contract for any specified period of time. I further understand that there are no other arrangements, agreements or understanding, oral or in writing, relating to the understanding set out in this paragraph and that the understanding set out herein supersedes any prior contrary statements. I further understand that any purported modifications to the understanding set out in this paragraph will not be effective unless in writing and personally signed by a representative of the District having actual authority to do so. (Initial below) I understand that this application will only be considered “active” for 30 calendar days from the date of application. If I have not obtained employment with the District within 30 days, but remain interested in obtaining employment with the District, I understand that I must complete a new application for my application to be considered for an additional 30 days. (Initial below) I hereby acknowledge that I have read and fully understand each of the above statements. (Initial below) Applicant's Signature Application Date:

Employment Application

APPLICANT INFORMATION

APPLICANT INFORMATION

POSITION APPLIED FOR

Education - High School (or Equivalent)

Business or Technical School

Undergraduate College or University

Graduate School

Other Schooling

License/Certificate Information

Military Service

Veterans' Preference

US Government Employment

Additional Training and Qualifications

Courses and Training

Employment History - Current Employer

Employment History - Former Employer #1

Employment History - Former Employer #2

Work Authorization

FOR DRIVER APPLICANTS ONLY

Professional References

Professional Resume

PLEASE READ BEFORE SIGNING