TALQUIN ELECTRIC COOPERATIVE, INC. P. O. Box 1679, Quinc y, FL 32353-1679 APP LICATION FOR EMPLOYMENT (WE ARE AN EQ UAL E MPLOYMENT OPPORTUNITY E MPLOYER) APPLI CANT'S STATEMENT I understand that the company is committed to providing equal o pportunity in all employment practices, including but not limited to selection, hiring, pro m oti on . tran sf er, and compensation to all qualified applicants and employees without regard to age, race, color, nation al origin. sex, religion, handicap or disability, or any other category p:rotected by federal, state, or local law. J authorize former and present employers, and prof essional. work, and personal references listed in the application and any other individuals I may name, to give the company or its designee any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release such parties from all liability for any damages that may r esult from furnishing same to the company. ] also authorize the company to provide truthful information concerning my employment with it to furore employers and I agree to hold it harmless for providing such information. I understand that the company reserves the right, to the extent permitted by law, to require drug and alcohol screening tests of an applicant or an employee either prior to employment or any time during employment and I hereby give my consent to any such tests. ] consent to the release of th e results of any such tests to the company or its designee. ] release the company and its designee from any and all liability and damages which may result or arise from any dru g test or the provision o f inform ation in connection with such a test. 1unde rstand that this employment application and any other company documents arc not promises of emp loyment. Should I be employed, ] understand that my employment will be on a trial period for ninety (90) days from the date of my hiring, and that I will remain an at-wi ll employee thereafter. I further unde rstand that, if I am employed, I can terminate my employment at any time with or without cause and with or without advance notice, and that the company has a similar right. I understand that no manager, representative, or agent of the company has any authority to enter into any agreement for employ ment for any specified period of time, or to make any agreement contrary to the foregoing, except that the President may do so in writing. The inf ormat ion given by me on this application and during the interview proc ess is true and complete in all respects, and I agree that if the information is found to be false, misleading, or unsatisfactory in any respect (in the company's judgment) that I will be disqualified from con sidera tion for emp loyment or subject to immediate dismissal if discovered after I am hired. I certify that I have received a separate written notification that the company may obtain a consumer report on me for use in connection with my application and, if 1 am hired, my employment with the company. I authorize the company to obtain this report. Th is ap plication will be co nsidered "active" for a maximum of thi rty (30) days. To be considered for employment after that time, you must reapply. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THESE STATEMENTS. D ate Applicant's Sienarure Each inquiry on this application must be.fulb: answered or completed. O therwise, you will not be considered for employment. PERSONAL DATA Last N ame First Name Middle Name Present Address How long have you lived there: Street and Number City, State, Zip Years Months Previous Address How long did you live there: Street and Number City, State. Zip Year s Months Telephone Numberfs) Social Security Number 1- Are you 18 years of age or older: D Yes 0 No Position Desired: Placement Desired: D Full-Time o Part-Time D Temporary When are you available for work:
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TALQUIN ELECTRIC COOPERATIVE, INC.P. O. Box 1679, Quincy, FL 32353-1679
APPLICATION FOR EMPLOYMENT(WE ARE AN EQ UAL E MPLOYMENT OPPORTUNITY EMPLOYER)
APPLI CANT'S STATEMENT
I understan d that the company is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring,pro motion . transfer, and compensation to all qualified applicants and employees without regard to age, race, color, nation al origin. sex, religion, handicapor disability, or any other category p:rotected by federal, state, or local law.
J authorize form er and present employers, and professional. work, and personal references listed in the application and any other individuals I may name,to give the company or its designee any and all information concerning my previous employment and any pertinent information they may have, personalor othe rwise and release such parties from all liability for any damages that may result from furnishing same to the company. ] also authorize thecompany to pro vide truthful information concerning my employment with it to furore employers and I agree to hold it harmless for pro viding suchinfo rmation.
I und erstand that the company reserves the right, to the extent permitt ed by law, to require drug and alcohol screening tests of an applicant or anemployee either prior to employment or any time during employment and I hereby give my consent to any such tests. ] consent to the release of th eresults of any such tests to the company or its designee. ] release the company and its designee from any and all liability and damages which may result orarise from any drug test or the provision o f information in connection with such a test.
1 unde rstand that this employment application and any other company documents arc not promises of employment. Should I be employed, ] understandthat my employment will be on a trial period for ninety (90) days from the date of my hiring, and that I will remain an at-wi ll employee thereafter. Ifurther unde rstand that , if I am employed, I can terminate my employment at any time with or without cause and with or without advance notice, and thatthe company has a similar right. I understand that no manager, representative, or agent of the compa ny has any authority to enter into any agreement foremploy ment for any specified period of time, or to make any agreement contrary to the foregoing, except that the President may do so in writing.
The informat ion given by me on this application and during the interview proc ess is true and complete in all respects, and I agree that if the information isfound to be false, misleading, or unsatisfactory in any respect (in the comp any's judgment) that I will be disqualified from considera tion for employmentor subject to immediate dismissal if discovered after I am hired.
I certify that I have received a separate written notification that the company may obtain a consumer report on me for use in connection with myapplication and, if 1 am hired, my employment with the comp any. I authorize the company to obtain this report.
Th is application will be considered "active" for a maximum of thi rty (30) days. To be considered for emplo yment after that time, you must reapply.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THESE STATEMENTS.
D ate Applicant's Sienarure
Each inquiry on this application must be.fulb: answered or completed. O therwise, you willnot be considered for employment.
PERSONAL DATA
Last N ame First Name Middle Name
Present Address How long have you lived there:Street and NumberCity, State, Zip
Years Months
Previous Address How long did you live there:Street and N umberCity, State. Zip
Year s Months
Telephone N umberfs) Social Security Number 1- Are you 18 years of age or older:D Yes 0 No
Position Desi red: Placement Desired: D Full-Time o Part-Time D Temporary
When are you available for work:
PREVIOUS EM PLOYMENT
Please list the names of your present or previous employees in chronological order with present or last employee listed first. Include part-time and seasonalemployment. If self-employed, give firm name and supply business references. DO NOT ANSWER "SEE RK~UME." Fill out this form completely.
Employer 1 D ates Emoloved Work PerformedFrom T o
Telephone N umber(s)
Ad dressHourlv Rate/Satarv
Starting FinalJob Title Supervisor
Name & Title
Reason for Leaving
Employer 2 Dates Employed Work Pe rformedFrom To
Telephone Number(s)
Address
Hourlv Rate/Salacv
Statting FinalJob Title Supervisor
N am e & T itle
Reason for Lea ving
Employer 3 Dates Employed Work PerformedFrom To
Telephone Number(s)
Addre ssHourlv Rare/Balarv
Starting FinalJob Title Supervisor
Name & T itle
Reason for Leaving
Employer 4 Dates Emnlcved Work PerformedFrom To
Telephone Number(s)
Address
Hourlv Rate/Salary
Starting FinalJob T itle Supervisor
N ame & T itle
Re ason for Leaving
BACKGROUND INFO~L-\TION
Please explain fully any gaps in your employment history. Be SlI r£ to accoun t for all pcriod~ of rime including military service and any period ofunemployment.
List any othe r nam es which you may have used and which will be necessary to verify prior to your employment:
If hired. can you provide proof that you are legally entitled to work in the U.S.? 0 Yes 0 No
If not, what steps must be taken fo r you to begin employment lawfuUy? _
I lave you ever been terminated or asked to resign from any job? D Yes 0 No
If yes, please explain circumstance s: _
May we contact your current employer? 0 Yes 0 No
If no , please exp lain:
Have you ever worked for this company before? 0 Yes 0 No
If yes, please give dates and position : _
1.)0 you have any friends or relatives wor king here? 0 Yes 0 No
If yes, Name(s) and Relationship: _
I low 'were you referred to us?
Have you ever pled «no contest," nolo, or guilty to a crime, or been convicted of a crime? 0 Yes 0 No
Are any charge s currently pending against you? 0 Yes 0 No
Has any adjudication ever been withheld? 0 Yes 0 N o
(NOTE : Answering " yes" to these questions does not constitute an automatic bar to employment.) If you answered yes to any of the preceding question s,please give dates and details:
Do you have any commitments to any ot her employer which may affect your employment? 0 Yes 0 ~o
If yes, explain: _
EDUCATION
Sch ool N ame Years Completed Diploma/Degree D escribe Course of D escribe Specialized Experien ce,(Ci.cle) Study or Major Training, Skills, an d Extra-Curricular
Activities
Elementary 4 5 6 7 8
H igh School 9 10 11 12
College/ Uni versity 1 2 3 4
Graduate /Profession al 1 2 3 4
T rade or Corresp ond ence
RELEVANT EXPERIENCE
Please indicate p osition s you have held in prior jobs:
