Metropolitan Water Reclamation District of Greater Chicago 100 East Erie Street, Chicago, IL 60611-2803 312-751-5100

EMPLOYMENT APPLICATION

– –
DATE / SOC. SEC. NO.
NAME / EXAMINATION
LASTFIRSTMIDDLE
ADDRESS / PHONE (HOME) / ()
CITY AND STATE / ZIP CODE / PHONE (WORK) / ()
Are you 16 years of age or older as of the date of this application? Yes No. If NO, a State of Illinois Work Permit is required.
Have you ever been convicted of a crime? Exclude convictions prior to your 18th birthday and minor traffic offenses. You are not obligated to disclose sealed or expunged records of conviction or arrest. Conviction is not an automatic bar to employment. Each case is considered on its individual circumstances. Yes No. If YES, explain and include dates on a separate page and attach to this application.
Where did you learn of this job? / By mail / Walk-in / Newspaper (which one?) / District employee
Magazine (which one?) / Web site (which one?) / Other (specify)
Education and Training:
HIGH SCHOOL LAST ATTENDED / CITY AND STATE
GRADUATE (OR GED)? Yes No DRIVERS LICENSE? Yes No / STATE / EXP. DATE
LISTALLCOLLEGE, UNIVERSITY OR POST GRADUATE WORK (LAST OR PRESENT SCHOOL FIRST) / DATES OF ATTENDANCE
MO. & YEAR / # OF CREDIT HOURS EARNED / DEGREE SOUGHT
(BS, etc.) / MAJOR FIELD OF STUDY / GRADUATED?
NAME OF SCHOOL / LOCATION / FROM / TO / QTR / SEM / YES / NO
BUSINESS, CORRESPONDENCE, TRADE, TECHNICAL OR VOCATIONAL SCHOOL / DATES OF ATTENDANCE
MO. & YEAR / # OF HOURS PER WEEK / MAJOR FIELD OF STUDY / COMPLETED?
NAME OF SCHOOL / LOCATION / FROM / TO / YES / NO

PROFESSIONAL OR OCCUPATIONAL LICENSES HELD:

TITLE / ISSUING AUTHORITY / REGISTRATION NUMBER / EXPIRATION DATE
Checked by: / APPLICANT: DO NOT WRITE BELOW / TIME STAMP
COMMENTS:
Date:
C.S. Exam / Temporary
Prom
Open
Qualified / Not Qualified

FOR ORIGINAL ENTRANCE EXAMINATIONS ONLY

VOLUNTARY EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

The Metropolitan Water Reclamation District considers applicants for all positions without regard for their race, color, religion, sex, age, national origin, disability or veteran’s status. The information requested below will be used for statistical purposes only. This information will be separated from your employment application and kept in a confidential file.

SUBMISSION OF THIS INFORMATION IS VOLUNTARY

Examination Title / Social Security Number
Age / Date of Birth / Male / Female
Please check one of the following Race/Ethnic Groups. (See reverse for category descriptions.)
White / African /Black American/Black / Hispanic / Asian/Pacific Islander / American Indian or Alaskan Native
Person with a disability? / Yes / No / Revised 1-12-04 DK
Printed on recycled paper

Employment Record - Attach Additional Sheets if Necessary

Instructions:
1. List present or most recent experience first
2. If you have more than one position or job title with a single employer, complete a separate box for each position held.
Organization Name / From (Mo./Yr)
Address / To (Mo./Yr.)
Your Title / Full Time / Part Time
Describe Duties / Hours per Week
Highest Salary $
Per: Year / Mo. / Hr.
Organization Name / From (Mo./Yr)
Address / To (Mo./Yr.)
Your Title / Full Time / Part Time
Describe Duties / Hours per Week
Highest Salary $
Per: Year / Mo. / Hr.
Organization Name / From (Mo./Yr)
Address / To (Mo./Yr.)
Your Title / Full Time / Part Time
Describe Duties / Hours per Week
Highest Salary $
Per: Year / Mo. / Hr.
Organization Name / From (Mo./Yr)
Address / To (Mo./Yr.)
Your Title / Full Time / Part Time
Describe Duties / Hours per Week
Highest Salary $
Per: Year / Mo. / Hr.
RESIDENCY REQUIREMENT: Any person who first becomes employed after December 31, 1987, or any former employee who returns to employment after that date must be domiciled within the boundaries of the Water Reclamation District. An employee on probationary status shall not be required to live within the territorial boundaries until six months after successful completion of probation. Failure to comply with this residency requirement shall be cause for removal or discharge from employment.
CERTIFICATION OF APPLICANT: I hereby certify that this application contains no misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I certify that I am a citizen of the United States, an alien lawfully admitted for permanent residence, or an alien authorized by the Immigration and Naturalization Service to work in the United States. I am aware that an investigation at any time disclosing any misrepresentations or falsification may result in my disqualification from this examination and/or termination of my employment. I further agree upon employment to be fingerprinted, to submit to a complete medical examination including a drug test by the District’s physician, and to furnish such proof of age, identity, employment experience, employment eligibility, academic achievement, and residence as required.
Signature of Applicant
RACE/ETHNIC CATEGORY DESCRIPTIONS
(Applies to equal employment opportunity information on reverse side)
The Equal Employment Opportunity Commission (EEOC) authorizes the use of the following race/ethnic categories:
a. White (not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
b. Black: All persons having origins in any of the Black racial groups of Africa.
c. Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
d. 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, India, Japan, Korea, the Philippine Islands, and Samoa
e. American Indian or Alaskan 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.

Revised 1-12-04 DK