( to print this application, print in landscape orientation)

               KITTERY  WATER  DISTRICT
                                          (An Equal Opportunity Employer)

                Application for Employment

PERSONAL INFORMATION

Name  ____________________________________Home Phone ___________________

Address ______________________  City _________________ State ______  Zip ______

Date of Birth * _________   Social Security # _____________  Cell Phone ____________

* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age
   with respect to individuals who are at least 40 years old but less than 70 years of age.

**Married:  (  ) YES   (  ) NO       Children:   (  ) YES    (  ) NO       Sex:  (  ) Male   (  ) Female
** Not intended to discriminate – may be left blank 

Citizen of the United States:  (  ) YES  (  )  NO   

      If no, are you lawfully authorized to work in the United States?  __________

      If you have a temporary work authorization give date of expiration ______________

Do you have a valid Commercial Driver's License (CDL): ______  If yes what class: ____

Do you have a valid driver's license: ______ State: ________  License #: ____________

Do you have any backhoe experience: _______________________________________

Do you have any experience installing water pipe: ______________________________

Do you have any other construction experience, knowledge or operation of machinery
that would be beneficial to our company: ____________________________________

______________________________________________________________________

Have you ever been convicted of a motor vehicle moving violation:  (   )  YES    (   )  NO

If yes  when:  _______________________  Explain violation: ____________________    

 _____________________________________________________________________

 Have you ever been involved in a motor vehicle accident:  (   )  YES    (   )  NO

 If yes  when:  ______________________  Explain accident: ___________________

 ____________________________________________________________________

 Have you ever been convicted of a felony:  (    )  YES    (    )  NO

 If yes when: ________________________  In what state: ______________________

 Describe the felony: _____________________________________________________

 POSITION APPLYING FOR:   ________________________________________________

Are you employed now: _____   If yes may we contact your present employer: _______

Have you ever applied to this company before: ________  If so when: ______________

                                                                                                             # Years       Did You
      EDUCATION                      Name & Location of School           Attended    Graduate      DATE
________________________________________________________________________

 Elementary School
________________________________________________________________________

 High School
________________________________________________________________________

 College
________________________________________________________________________

 Trade School
________________________________________________________________________

 Other
________________________________________________________________________

Have you ever served in the U.S. military: ______ Branch: ________ Dates: __________

Type of Discharge: __________   Currently serving in National Guard or Reserves: ______

Subjects of special study or other relevant experience: ___________________________

_______________________________________________________________________

EXPERIENCE            (List most recent employer first)     

(1)    Dates Employed:    From ____________________  to  _______________________

 Name of Company:  ___________________________________  Salary:_____________

 Address:  ___________________________________  Telephone:  (      ) _____________

 Position Held: ___________________________    Supervisor: _____________________

 Duties Performed: ________________________________________________________

                                  ________________________________________________________

                                  ________________________________________________________

Reason for Termination:____________________________________________________

-------------------------------------------------------------------------------------------- 

(2)    Dates Employed:    From ____________________  to  ______________________

Name of Company:  __________________________________   Salary: _____________

Address:  ___________________________________  Telephone:  (      ) _____________

Position Held: ________________________    Supervisor: ________________________

Duties Performed:  ________________________________________________________

                                  ________________________________________________________

                                  ________________________________________________________

Reason for Termination: ____________________________________________________

--------------------------------------------------------------------------------------------

(3)    Dates Employed:    From ____________________  to  ______________________

Name of Company:  _____________________________________  Salary: ___________

Address:  _____________________________________ Telephone:  (      ) ___________

Position Held: _________________________    Supervisor: _______________________

Duties Performed:  ________________________________________________________

                                  ________________________________________________________

Reason for Termination: ____________________________________________________

-------------------------------------------------------------------------------------------- 

REFERENCES

Please give the names of three (3) persons Not Related To You, whom you have known
at least one (1) year.
                                                                                                                  HOW                 YEARS        
NAME                       ADDRESS                      TELEPHONE                AQUAINTED       AQUAINTED
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

PHYSICAL  RECORD

Do you have any physical limitations that preclude you from performing any work for
which you are being considered:   (    )  YES    (    )  NO

If yes, please describe: ___________________________________________________

  _____________________________________________________________________ 

 In case of an emergency, who should we contact:

 NAME: ________________  ADDRESS: ______________________  TELE: ___________

Will you consent to:  A Drug Test (   )YES (   )NO  A Physical Examination (   ) YES (   ) NO

        “ I certify that the facts contained in this application are true and complete to the
best of my knowledge. I understand that, if employed, falsified statements on this
application shall be grounds for dismissal.

          I authorize investigation of all statements contained herein and the references
listed above to give you any and all information concerning my previous employment
and any pertinent information they may have, personal or otherwise, and release all
parties from all liability for any damage that may result from furnishing same to you.
I also authorize that a background check be performed and released to the Kittery
Water District Human Resource Department.”

 NAME: ____________________________________   DATE: _____________________

 SIGNATURE: ___________________________________________

 ( Please feel free to attach your resume)