OMRPWA

OZARKMOUNTAIN REGIONAL PUBLIC WATER AUTHORITY

Employment Application

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Social Security No. / Desired Salary
Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

Education

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional references.
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address

Previous Employment

Are you currently employed?YES NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge
If other than honorable, explain

Job skills

List any job skills or special training you have for the position you are applying for:

EXPERIENCE AND QUALIFICATIONS

Do you possess a valid Water TreatmentOperatorLicense in the State of Arkansas as distributed by the Arkansas Department of Health?
YES NO If YES, What Grade? Grade I Grade II Grade III Grade IV
Do you possess a valid Water Distribution OperatorLicense in the State of Arkansas as distributed by the Arkansas Department of Health?
YES NO If YES, What Grade? Grade I Grade II Grade III Grade IV
List experience with management and operation withsurfacewater treatment plants (provide details about treatment process type(s), plant size(s), water source(s), etc.): Demonstrate knowledge of the Surface Water Treatment Rule.
List experience with automatic computer controls, instrumentation, SCADA systems, radio telemetry, or any other computer monitoring equipment commonly used in water treatment plants: List experience with electrical systems within water treatment plants:
List water utility management experience including employee supervision, evaluation, training, discipline, etc.:
List experience with preparation, monitoring and abiding by annual budgets for water utilities:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
I authorize former employers to release to the Ozark Mountain Regional Public Water Authorityor its authorized representative any and all employment records and other information it may have about my employment. I understand that the information will be used for the purpose of evaluating my application for employment with the OMRPWA. A photocopy of this authorization shall be as valid as the original.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
Signature / Date

OMRPWA

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