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PEOPLE'S ELECTRIC COOPERATIVE
Employment Application
Date:11/13/19
Your application be considered active for a period of six (6) months and thereafter retired to an inactive file for one (1) year. You may renew this application by filing a new form. The following information is requested in order to help us make the best possible placement within the Cooperative. All portions of this application pertaining to you must be completed. We appreciate the time you spend in filling in this application form. The Cooperative, in accordance with State and Federal laws, does not discriminate on the basis of age, race, religion, color, sex (including pregnancy), national origin, disability or veterans status. The Cooperative also is required by law, by virtue of its contract(s) with the federal government, to take affirmative action to employ women, minorities, otherwise qualified disabled individuals, and Vietnam era and disabled veterans. Applicants applying for positions that require them to drive Cooperative vehicles must also fill out the Driver's Supplemental Application for Employment.
Position For: (Job Choice 1)
(Job Choice 2)
(3 - other)
APPLICANT INFORMATION
Name (Last) (First) (Middle)
Address (Street) Telephone No.
(City) (State) (Zip) Alternate No.
S.S. Number / / Email
Do you have the legal right to work in the United States? YESNO
How were you referred to the Cooperative?
Are you related, by blood or marriage, to any existing employee of the Cooperative or to a present member of the Board of Trustees?
(A list of present employees and trustees will be provided upon request.)
YESNO
If yes, state name and relationship
Have you ever applied for a job with the Cooperative? YESNO
If yes, when?
Have you ever worked at the Cooperative before? YESNO
Can you perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? YESNO
Salary Expected per
Apart from absence for religious observation, are you available to work from 8:00 a.m. to 5:00 p.m. Monday through Friday? YESNO
If no, what hours can you work?
Will you work overtime if asked? YESNO
Are you willing to work after hours call-out duty and on-call assignments? YESNO
List any friends or aquaintances presently working for the Cooperative.
Are you at least eighteen years of age? YESNO
Have you ever been convicted of a felony? YESNO
If yes, give details, including jurisdiction (state and county) where such conviction occurred.

(Criminal convictions are not an absolute bar to employment. They will only be considered in relation to specific job requirements.)
Have you ever been convicted of a power (electricity) theft or power diversion? YESNO
If yes, give details, including jurisdiction (state and county) where such conviction occurred.
In what state or states do you possess a valid and current driver's license?
In what state or states have you ever possessed a driver's license?
If you are selected for employment, on what date can you start work?
EDUCATION
  SCHOOL NAME ADDRESS NO. OF YEARS
ATTENDED
DEGREE MAJOR
HIGH
COLL.
OTHER
Courses now studying:
PREVIOUS EMPLOYMENT RECORD (Most recent employer first)
DATES NAME AND ADDRESS
OF EMPLOYER
JOB TITLE AND BRIEF
DESCRIPTION OF DUTIES
SALARY EXACT REASON
FOR LEAVING
From:
From
To:
To
May we
contact them?
YESNO
Telephone Supervisor:
 
From:
From
To:
To
May we
contact them?
YESNO
Telephone Supervisor:
 
From:
From
To:
To
May we
contact them?
YESNO
Telephone Supervisor:
 
From:
From
To:
To
May we
contact them?
YESNO
Telephone Supervisor:
Attach additional sheets if necessary.
List any additional trainings, certifications, or special skills.
List your membership in any professional or technical organizations that are related to the job requirements of the position for which you are applying (exclude those that may disclose your race, color, religion, sex, age, national origin, physical or mental disability, veteran status or union affiliations).
PERSONAL REFERENCES (Please do not list relatives.)
Name and Occupation Address Phone Number
IMPORTANT! READ THIS!
CERTIFICATION
I certify that all information provided in support of my employment with the Cooperative, including but not limited to this application, resumes, medical information, and information provided by me during interviews, is correct to the best of my knowledge, and I understand that misrepresentation or omission of relevant facts in seeking employment will result in my disqualification from further consideration or my dismissal from employment. I agree to conform to the rules and regulations of the Cooperative, and I understand that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of the Cooperative or myself. I further understand that no person is authorized to make any representation contrary to the above statement unless such representation is approved by the Board of Directors and is embodied in a written agreement signed by the President or the CEO of the Cooperative. I further understand that if offered fulltime employment, I will be required to take a physical examination and that such examination will include blood, breath, urine, or saliva tests to determine the presence or use of alcohol or illegal controlled substances.

Signature of applicant
 
Date

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