ERBA - Application for Employment

Application for Employment
EMBARRAS RIVER BASIN AGENCY, INC.

400 W. PLEASANT ST. P.O.BOX 307
GREENUP, IL 62428
APPLICATION FOR EMPLOYMENT
ERBA is committed to a policy of nondiscrimination and full equity of opportunity, regardless of race, religion, color, disability, marital status, veteran status, sex, age, national origin, political affiliation or belief. We are an equal opportunity employer.

Please complete this application in ink or type and attach resume. Mail or deliver to address shown above.
Position Applied For
Location
Last Name
First Name
Middle Init
Street
City
State
Zip
Telephone Number
County of Residence
Drivers License Number
Expiration date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Email
example@example.com
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.

YesNo
Date available for work

MonthDayYear
Date
What is your desired salary range?
List any friends or relatives that work for us
Were you referred by an ERBA employee? If yes, please list one
Note to applicants: DO NOT ANSWER THE FOLLOWING FOUR QUESTIONS UNTIL YOU HAVE BEEN

PROPERLY INFORMED ABOUT THE JOB REQUIREMENTS FOR WHICH YOU ARE APPLYING.

1. Do you have any disabilities that would interfere with job performance? (In order that we may reasonably accomodate those disabilities) 2. Describe disabilities and specific work limitations 3. Have you been convicted of a crime that would relate to the position you are applying for?

4. Have you had an illness in the past 5 years that would prohibit you from doing this job?

Person to be contacted in case of accident or emergency
Education
Education - School #1
# of years completed #1
Name and Address of School #1
Major or Field #1
Indicate Diploma, Credit or Degree#1
Type of School #2
# of years completed #2
Name and Address of School #2
Major or Field #2
Indicate Diploma, Credit or Degree #2
Type of School #3
# of years completed
Name and Address of School #3
Major or Field #3
Indicate Diploma, Credit or Degree #3
EMPLOYMENT HISTORY (Start with current)
Last or Current Employer (Please supply Supervisor's Name) #1
Employment Date to and from #1
Type of Work & Business Address and Phone #1
Reason for leaving #1
Last or Current Employer #2
Employment Date - to and From #2
Type of Work - Business Address and Phone #2
Reason for Leaving #2
Employer #3
Employment Dates - To and From #3
Type of work - Business Address and Phone #3
Reason for Leaving #3
Employer #4
Employment Date - To and From #4
Typer of Work - Business Address and Phone #4
Reason for Leaving #4
REFERENCES (please do not include family members)
Full Name #1
Address and Phone #1
Business or Occupation #1
Reference Full Name #2
Address and Phone #2
Business or Occupation #2
Reference Full Name #3
Address and Phone #3
Business and Occupation #3
Reference Full Name #4
Address and Phone #4
Business or Occupation #4
Reference Full Name #5
Address and Phone #5
Business or Occupation #5
Mark the box if applicant is claiming Veterans Preference and has provided forms.
I give permission to E.R.B.A. in obtaining and verifying employment and personal references necessary to make a hiring decision and hold the agency and persons giving such references harmless and free of any and all liability that could result from this review process. All information received will be held in strict confidence. Within this permission is authority to the ERBA representative to make investigation of my personal history through any agency or bureau.

CERTIFICATION - I certify that all the statements made by the applicant in this Employment Application are true, complete and correct to the best of my knowledge and belief, and are made in good
Applicant Signature

Clear
Date Signed

MonthDayYear
Date
Affirmation Action Survey

State and Federal agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntary.
Select One:

MaleFemale
Select One - Age:

Under 2121 to 5960 and Over
Select One - Race

WhiteAfrican AmericanHispanicAmerican Indian/Alaska NativeAsian/Pacicifc IslanderOther
Type a question

VeteranVeteran with DisablitiesNon Veteran with Disabilities
Should be Empty:

GREENUP, IL 62428

APPLICATION FOR EMPLOYMENT