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APPLICATION FOR EMPLOYMENT

 

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

All qualified applicants will receive consideration for employment without regard to race, color,

religion, sex, sexual orientation, gender identity, age, national origin, disability or veteran status.

 

(PLEASE PRINT)

Date of Application:   _______________________________________________________________________________________

Position Applying For:   _____________________________________________________________________________________

Did you receive a copy of the job description for the position you are applying for?                         o Yes       o No

Name (Last, First, Middle): ___________________________________________________________________________________

Address (Number, Street, City State and Zip Code): __________________________________________________________

_______________________________________________________________________________________________________________

Telephone Number(s): _______________________________________________________________________________________

Do you have the legal right to work in the United States?                                                                        o Yes       o No

(Proof of citizenship or immigration status will be required upon employment.)

How were you referred to us? __________________________________________________________________________________

Have you ever filed an application with us before?                                                                                     o Yes       o No

If yes, when?   ____________________________________

Have you ever been employed with us before?                                                                                           o Yes       o No

If yes, when?   ____________________________________

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

In what state or states do you possess a valid current driver’s license? ____________________________________

In what state or states have you ever possessed a driver’s license?   _______________________________________

Can you perform the essential functions of the job for which you are applying?                                   o Yes       o No

(See attached job description for a list of essential functions of the job for which you are applying.)

Are you currently employed?                                                                                                                          o Yes       o No

If yes, may we contact your present employer?                                                                                           o Yes       o No

On what date would you be available for work? ____________________________________________________________

PERSONAL REFERENCES

Give name, occupation, address and telephone number of three references who are not related to you and are not previous employers.

  1. __________________________________________________________________________________________________________________
  1. __________________________________________________________________________________________________________________
  1. __________________________________________________________________________________________________________________

Apart from absence for religious observation, are you available to work from 8:00 a.m.

to 5:00 p.m. Monday through Friday?                                                                                                               o Yes       o No

If no, what hours can you work? _______________________________________________________________________________

Will you work overtime if asked?                                                                                                                       o Yes       o No

Are you willing to work after hours call-out duty and on-call assignments?                                              o Yes       o No

Have you ever been convicted of a felony?                                                                                                     o Yes       o No

(Convictions will not necessarily disqualify an applicant from employment.)

If yes, give details: ____________________________________________________________________________________________

________________________________________________________________________________________________________________

Have you ever been convicted of a power (electricity) theft or power diversion?                         o Yes       o No

If yes, give details: ____________________________________________________________________________________________

________________________________________________________________________________________________________________

EDUCATION

 

High

School

Undergraduate

College/University

Graduate

Professional

School Name and Location

     

Years Completed

1     2     3     4

1     2     3     4

1     2     3     4

Diploma, Degree or Major

     

(On the next three items, please exclude those that may disclose your race, creed, color, religion, sex, national origin, ancestry, age, disability, veteran status, union affiliation, or any other protected category.)

Describe any specialized training, apprenticeship, skills and extra-curricular activities. _______________________

______________________________________________________________________________________________________________________

Describe any honors you have received. _________________________________________________________________________

______________________________________________________________________________________________________________________

State any additional information you feel may be helpful to us in considering your 

application.  ___________________________________________________________________________________________________________

EMPLOYMENT EXPERIENCE

Start with your present job or last job.  Include any job-related military service assignments and volunteer activities.

(You may exclude organizations that indicate race, color, religion, national origin, age, ancestry, or handicap or other protected status.)

(1)

Employer:  ______________________________________________________________________________________

Address:   _______________________________________________________________________________________

Telephone Number(s):   _________________________________________________________________________

Dates Employed:                                                                           Hourly Rate/Salary:

From __________________ To _________________         Starting __________________ Final __________________

Job Title:   ____________________________________       Supervisor:   __________________________________

Work Performed:  _________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Reason for Leaving:  _______________________________________________________________________________________________

(2)

Employer: _____________________________________________________________________________________________

Address:  _______________________________________________________________________________________________

Telephone Number(s): _________________________________________________________________________________

Dates Employed:                                                                           Hourly Rate/Salary:

From __________________ To _________________         Starting ________________ Final _______________

Job Title:  ________________________________           Supervisor:  ________________________________

Work Performed:  __________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Reason for Leaving:  ________________________________________________________________________________________________

(3)

Employer:  _____________________________________________________________________________________

Address:   ______________________________________________________________________________________

Telephone Number(s):  _________________________________________________________________________

Dates Employed:                                                                           Hourly Rate/Salary:

From __________________ To _________________         Starting ________________ Final _______________

Job Title:   __________________________________       Supervisor: ___________________________________

Work Performed: ____________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Reason for Leaving:  __________________________________________________________________________________________________

(4)

Employer:  _____________________________________________________________________________________

Address:  _______________________________________________________________________________________

Telephone Number(s):  _________________________________________________________________________

Dates Employed:                                                                           Hourly Rate/Salary:

From __________________ To _________________         Starting ________________ Final _______________

Job Title:  __________________________________        Supervisor:  __________________________________

Work Performed: _____________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

Reason for Leaving:  ___________________________________________________________________________________________________

If you need additional space, please continue on a separate sheet of paper.

Special Skills and Qualifications.  Summarize special job-related skills and qualifications acquired from employment or other experience, which would be or are related to the position you are applying for,

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT, UNLESS OTHERWISE DEFINED BY APPLICABLE LAW, ANY EMPLOYMENT RELATIONSHIP WITH THIS ORGANIZATION IS OF AN “AT WILL” NATURE, WHICH MEANS THAT THE EMPLOYEE MAY RESIGN AT ANY TIME AND THE EMPLOYER MAY DISCHARGE AT ANY TIME WITH OR WITHOUT CAUSE.  IT IS FURTHER UNDERSTOOD THAT THIS “AT WILL” EMPLOYMENT RELATIONSHIP MAY NOT BE CHANGED BY ANY WRITTEN DOCUMENT OR BY CONDUCT UNLESS SUCH CHANGE IS SPECIFICALLY ACKNOWLEDGED IN WRITING BY AN AUTHORIZED EXECUTIVE OF THIS ORGANIZATION.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

_______________________________________________________       ___________________

Signature of Applicant                                                                                Date

Voluntary Self-Identification of Race, Ethnicity and Gender

Southeastern Electric Cooperative, Inc. (hereinafter “the Cooperative”) is subject to certain federal government recordkeeping and reporting requirements for the administration of civil rights laws and regulations.  In order to comply with these laws, the Cooperative invites applicants/employees to voluntarily self-identify their race, ethnicity and gender.  Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.  The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported annually to the federal government for civil rights enforcement.  When reported, data will not identify any specific individual.

ETHNICITY

¨    Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

RACE

¨    American Indian or Alaskan Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.

¨    Asian (not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

¨    Black or African American (not Hispanic or Latino) - A person having origins in any of the Black racial groups of Africa.

¨    Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

¨    White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

¨    Two or More Races (not Hispanic or Latino) - All persons who identify with more than one of the above five races.

GENDER

¨    Male

¨    Female

 

 

 

Applicant’s/Employee’s Name: ___________________________________________            Date: ________________

 

 

Note: If an employee declines to self-identify, employment records or observer identification may be used.

 

 

Southeastern Electric Cooperative, Inc. (Southeastern)

“Pre-Offer” Invitation to Self-Identify as a Protected Veteran

Southeastern is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

  • A ‘‘disabled veteran’’ is one of the following:
    • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • a person who was discharged or released from active duty because of a service- connected disability.
  • A ‘‘recently separated veteran’’ means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An ‘‘active duty wartime or campaign badge veteran’’ means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An ‘‘Armed forces service medal veteran’’ means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1–866–4–USA–DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

  •    I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE

 

  • I AM NOT A PROTECTED VETERAN                                                                            

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.  The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Southeastern shall not discriminate against protected veterans and shall take affirmative action to employ and advance in employment qualified protected veterans at all levels of employment, including the executive level.  Furthermore, Southeastern will recruit, hire, train and promote persons in all job titles, and ensure that all other personnel actions are administered without regard to protected veteran status, and will ensure that all employment decisions are based only on valid job requirements.

                                                                                                                                                                                          

Name _________________________________________________________           Date_____________________________

 

 

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017

Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

□ YES, I HAVE A DISABILITY (or previously had a disability)

□ NO, I DON’T HAVE A DISABILITY

□ I DON’T WISH TO ANSWER

 

Your Name: _____________________________________________________       Today’s Date: _____________________

 

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017

Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT:  According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  This survey should take about 5 minutes to complete.