PEC Application for Employment Step 1 of 5 20% Your Personal InformationYour Name First Middle Last Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your PhoneYour Email Address Date Available MM slash DD slash YYYY Desired SalaryPosition Applied forAre you authorized to work in the U.S.Proof of authorization will be required under federal law if employment begins. Yes No Have you ever worked for this company? Yes No If yes, when?Have you ever been convicted of a felony?Conviction is not necessarily a bar to employment. We will consider the nature and gravity of the offense, when it occurred, and the nature of the job sought. Yes No If yes, explain. EducationHigh SchoolHigh SchoolAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Did you graduate? Yes No DiplomaCollegeCollegeAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Did you graduate? Yes No DiplomaFrom MM slash DD slash YYYY To MM slash DD slash YYYY OtherOtherAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Did you graduate? Yes No DiplomaFrom MM slash DD slash YYYY To MM slash DD slash YYYY ReferencesReference 1Name First Last CompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code RelationshipPhoneReference 2Name First Last CompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code RelationshipPhoneReference 3Name First Last CompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code RelationshipPhoneCurrent EmployerCompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneSupervisor First Last Job TitleResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your supervisor for a reference? Yes No Previous EmploymentCompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneSupervisor First Last Job TitleResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your supervisor for a reference? Yes No Previous EmploymentCompanyAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneSupervisor First Last Job TitleResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your supervisor for a reference? Yes No Military ServiceBranchFrom MM slash DD slash YYYY To MM slash DD slash YYYY Rank at DischargeSpecial TrainingService Awards Terms and Conditions(Required)I hereby declare that the information, which is being provided by me in this application for employment, is true, correct, and complete to the best of my knowledge. I understand that falsification of this application in any way whatsoever, or misstatement or omission of fact on this application, shall be grounds to deny me employment. If Pickwick Electric Cooperative (“PEC”) employs me, I understand that this application will become part of my official employment record. I further understand that falsification of this application in any way whatsoever, or misstatement or omission of fact on this application, shall be considered cause for immediate dismissal, regardless of when the falsification, misstatement or omission is discovered. I authorize PEC to obtain investigative reports containing information as to my character, personal characteristics, and work experience. I understand that I have the right to make a written request (within a reasonable period of time) to receive information regarding the investigation. I hereby give consent to any and all prior employers of mine to provide information with regard to my employment with prior employers to PEC. I understand and acknowledge that if employed, my employment with PEC will be “at will”, meaning that either I or PEC may terminate my employment at any time for any reason or no reason, unless the “at will” arrangement is modified by an applicable collective bargaining agreement, or a written agreement signed by both the President of PEC and me. I acknowledge that I do not rely and have not relied on any representations or statements made by PEC or any of its agents or representatives, whether oral or written, that are inconsistent with, or differ in any way from, the statements presented in this application. I understand that no agent or representative of PEC, other than the President, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any agreement or assurances contrary to the “at will” nature of the employment relationship. I also understand that this application is not a contract of employment. I specifically understand and acknowledge that if I am employed, my “at will” employment with PEC is for no specific duration and can be terminated at any time. By my signature on this application, I authorize PEC to conduct reference checks, with former employers and other persons named in this application, for the purposes of providing the Company with any relevant information which is required for employment, and I release all persons contacted by PEC during the hiring process from any liability for any damage whatsoever resulting from giving the Company this information. Should PEC employ me, I authorize its representatives to furnish information regarding my employment at the Company if such information is requested in the future. I release PEC and its representatives from any liability for any damage whatsoever resulting from furnishing this information. I have read and understand the contents of this employment application and am fully able and competent to complete it. I voluntarily consent and agree to the foregoing statements. I agree to the terms and conditions.SignatureDate MM slash DD slash YYYY
