Employment Application

General Information

Position Applied For*

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email Address*

Are you under the age of 18?*

Yes

Are you related by blood or marriage to any of the following persons: an employee of Gascosage Electric Cooperative, a member of the Gascosage Electric Board of Directors, or the Manager of Gascosage Electric Cooperative?*

Yes

If the answer is "yes", state the name(s), relationship(s), and the position(s) held by the person(s) to whom you are related.

Are you presently legally authorized to work in the U.S. on a full time basis? You will be required as a part of the application process to provide any employment eligibility verification mandated by the Federal Government.*

Yes

Are you willing to travel as part of this job?*

Yes

Have you ever been employed by Gascosage Electric?*

Yes

If yes, provide dates of employment

Have you ever been convicted of (or plea bargained to) a misdemeanor or felony?

Yes

If yes, state nature, resolution and date of the case(s)

Education/Training History

Do you have a high school diploma or a general education development (GED) certificate?

Yes

If yes, provide name & location of school

List colleges, military, business, trade or other schools attended

For each school, please include: Institution Name and Location, Dates attended, Major/minor areas of study (if applicable), Degree awarded, Grade Point Average and Year degree was received.

License/Registration Certificate

List any required professional license, registration, certificate, Commercial Driver's License, etc.

Include Description, State, Number, Expiration

Specialized Skills and Knowledge

Computer Skills

Excel

Microsoft Word

InDesign

Powerpoint

Access

Adobe Photoshop

Office Skills

10 Key Sight/Touch

Accounting

A/P

A/R

Payroll

General Ledger

Purchasing

Other special skills

List skills or knowledge that show your ability to perform the job for which you are applying.

Foreign Language - Specify Fluency (Reading, Speaking and/or Writing)

Additional comments

Military Experience

Branch of Service

Rank/Rate

Dates From/To

Type of discharge

General duties/training

Disabled Veteran

Percent of Disability

Service Medals

References

Lis 3 current references who are familiar with your work-related abilities and background. Do not list relatives.

Name

First Last

Professional Relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email Address

Name

First Last

Professional relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email Address

Name

First Last

Professional relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Name

First Last

Professional relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Name

First Last

Professional Relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email Address

Accommodation Information

IN SUPPORT OF THE AMERICANS WITH DISABILITIES ACT, SPECIAL ARRANGEMENTS MAY BE MADE FOR CERTAIN DUTIES OF CERTAIN POSITIONS IN ORDER TO ACCOMMODATE A PHYSICAL OR MENTAL IMPAIRMENT OR DISABILITY. YOU ARE NOT REQUIRED TO DISCLOSE SUCH INFORMATION THAT YOU BELIEVE WILL NOT INTERFERE WITH YOUR CAPABILITY TO DO THE JOB. HOWEVER, IF YOU WANT THE COOPERATIVE TO CONSIDER SPECIAL ARRANGEMENTS TO ACCOMMODATE A PHYSICAL OR MENTAL IMPAIRMENT DURING THE SELECTION PROCESS OR CONCERNING THE POSITION FOR WHICH YOU HAVE APPLIED, YOU NEED TO IDENTIFY THE DISABILITY AND THE REQUESTED ACCOMMODATION BELOW.

Disability or Handicap

Type of Accommodation Needed

Work Requirements

What date would you be available for work?

Are you available to work

Full time?

Part time?

Temporary?

Other Qualifications

List job-related training courses by title and year. List honors, awards, volunteer work, and special accomplishments. (publications, memberships in professional/honor societies, leadership activities, public speaking, performance awards, etc.)

Previous Employment

Name of Employer

Type of business

Job title

Dates from/to

Employer's address and phone

Supervisor's name and phone

Hours worked per week

Reason for leaving

List Duties/Responsibilities/Accomplishments/Equipment Utilized

May we inquire of current employer?

Yes

Name of employer

Type of business

Job title

Dates from/to

Employer's address and phone

Supervisor's name and phone

Hours worked per week

Reason for leaving

List Duties/Responsibilities/Accomplishments/Equipment Utilized

May we inquire of current employer?

Yes

Name of employer

Type of business

Job title

Dates from/to

Employer's address and phone

Supervisor's name and phone

Hours worked per week

Reason for leaving

List Duties/Responsibilities/Accomplishments/Equipment Utilized

May we inquire of current employer?

Yes

Please use this section to provide any additional information you feel is relevant to this position.

Resume

Max. file size: 10 GB.

Applicant Authorization

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH, THEN SIGN AND DATE BELOW.*

I certify that the facts contained in this application and attached documentation for employment with Gascosage Electric Cooperative are true, correct, and complete to the best of my knowledge. I understand that any misrepresentations, falsifications, or deliberate omissions will result in my immediate dismissal.

Policy 315: (Nepotism) The term "family members" for the purpose of this policy shall mean and include any person who, by blood or marriage (including in-law, half, foster, step and adopted), is a spouse, child, grandchild, parent, grandparent, brother, sister, aunt, uncle, nephew, niece or first cousin of any employee or director.

I authorize investigation of all statements herein. I also authorize by my signature below or a copy thereof, the organizations and individuals referred to herein to furnish information to the Cooperative. I also authorize the Cooperative to obtain any information pertaining to my juvenile or adult criminal justice, employment, medical, psychological background, credit records, military service and educational records. The Cooperative shall be held harmless should it, in processing this employment application, rely on information provided from these sources, even if the information provided is inaccurate or erroneous.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview or in any policies, procedures or handbooks that I might receive, is intended to create an employment contract between Gascosage Electric Cooperative and me. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Cooperative. If an employment relationship is established, I understand that I have a right to terminate my employment at any time, for any reason or for no reason, and Gascosage Electric Cooperative retains a similar right.

Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, or a work schedule that includes Saturday and/or Sunday. I understand and accept these as conditions of employment if hired.

Gascosage Electric Cooperative is a drug-free and alcohol-free workplace. I understand that random drug and alcohol screenings are performed, and agree to these conditions.

In the event that I am hired, I will abide by all of the Cooperative's rules, regulations, policies and practices, and understand that these may be changed from time to time at the discretion of the Cooperative.

Signature

Affirmative - Completion is voluntary

GASCOSAGE ELECTRIC COOPERATIVE IS REQUIRED TO PROVIDE STATISTICAL REPORTS TO GOVERNMENTAL AGENCIES ANALYZING AND MONITORING AFFIRMATIVE ACTION EFFORTS. THE INFORMATION REQUESTED BELOW WILL BE USED FOR THE COMPILATION OF STATISTICAL REPORTS AND RECORD KEEPING PURPOSES, AND NO INFORMATION PROVIDED WILL BE USED IN AN UNLAWFUL MANNER. THE INFORMATION WILL NOT BE KEPT WITH THE APPLICATION OR PERSONNEL FILE AND WILL IN NO WAY AFFECT THE HIRING DECISION.

Position Applied For

Race/Ethnicity

BLACK (not of Hispanic origin) - All persons having origins in any of the black racial groups of Africa.

HISPANIC - All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race.

ASIAN OR PACIFIC ISLANDER - All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.

AMERICAN INDIAN or ALASKA NATIVE - All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. Please identify with which tribe you are affiliated.

WHITE (not of Hispanic origin) - All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.

Sex

Male

Female

Disable Data

DISABLED INDIVIDUAL - Person who (1) has a physical or mental impairment which substantially limits one or more major life activities, or (2) has a record of such impairment, or (3) is regarded as having such impairment.

Veteran Data

DISABLED VETERAN - Personal entitled to disability compensation under law administered by Veterans Administration for disability rated 30% or more OR person discharged/released from active duty for disability incurred or aggravated in line of duty.

Veteran

Referral Source

State Employment Office

Newspaper Ad (specify newspaper)

Website

Friend/Relative

Social/Community Organization (specify)

Current Gascosage Employee

Private Employment Agency

Other Publication (specify)

Self Referral - Walk-In, Write-In, Phone-In

Other referral source:

Digital Signature