Customer Information Portal
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on this application will sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.
I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.
I represent and warrant that I have read and fully understood the foregoing, and that I seek employment under these conditions.
The above named applicant is being considered for employment with East Fork Special Utility District and has listed your organization as a former employer. We would appreciate your verification and completion of this form at your earliest convenience. Information provided will be treated in confidence. Please return this form to us in the enclosed, self-addressed, stamped envelope. Thank you for your assistance.
Applicant’s Authorization
I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, relating to my employment with the former employer. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment. I also hereby release the above name former employer, and it agents and employees, from all liability for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information.
EFSUD Office Use Only
Record of Employment
Position held: _____________________________ Dates employed: ______________________
Summary of essential duties: ______________________________________________________
Reason for leaving: ______________________________________________________________
Salary at termination: ________________________ Eligible for rehire? _____ Yes _____ No
Please rate the following: Excellent Good Average Fair Poor
Job Knowledge ___ ___ ___ ___ ___
Accuracy ___ ___ ___ ___ ___
Productivity ___ ___ ___ ___ ___
Dependability ___ ___ ___ ___ ___
Attendance ___ ___ ___ ___ ___
Overall Performance ___ ___ ___ ___ ___
Comments: ___________________________________________________________________
Signature: ____________________________ Title: _______________________Date: _____
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