APPLICATION FOR SEASONAL EMPLOYMENT

NOTE: All applicants must be 18 yrs or older, possess a valid drivers license. Office/Radio dispatcher must be able to work through the 2^nd FULL week of August.

Name ___________________________________________________________ Daytime Phone____________

Last First Middle

Home Address ________________________________________________________________________________________

Street Town State Zip

Mailing Address _______________________________________________________________________________________

Street Town State Zip

Current School and Year ________________________________________________________

Social Security # ______________________ T-Shirt Size: S M L XL Shoe Size __________

(Field Oper. Only)

# Previous Years Employed by NWMAD _______ Position Held ________________________

How did you hear about this job? ________________________

If referred by current employee enter name __________________________________ (one name only)

Date Available to Start __________________ Ending Date ________________

(Note: failure to include & abide by stated start & end dates may result in employment disqualification, dismissal and/or loss of length-of-stay bonus, Seasonal mosquito control work may be available to Sept. 30th)

Work Location Preference: Wheeling ____ Elk Grove ____ Hoffman Est. ____

(Please indicate 1,2,3 choice, Office and Lab only at Wheeling)

NOTE: At times, due to the unpredictable nature of mosquito control work, extended hours will be required of all field operations personnel in the form of 9 hour shifts, evening adulticiding work and Saturday day-time work. Please initial below indicating your acknowledgement of these requirements. Failure to comply with the above requirements constitutes grounds for dismissal or disqualification from employment consideration.

____________ I will be available for 3 evenings/week Monday – Friday, 9 hour shifts and Saturdays when required. I will not take a leave of absence which extends beyond 3 consecutive days between my starting and ending dates.

In Case of Emergency Notify ___________________________________________________________________________

Name Telephone

Former Employers

________________________________________________________________________________________________

Name Address Telephone

Dates of Employment From _______ to _______

MO/YR MO/YR

________________________________________________________________________________________________

Name Address Telephone

Dates of Employment From ______ to ______

MO/ YR MO/YR

References (2)

________________________________________________________________________________________________

Name Address Telephone

________________________________________________________________________________________________

Name Address Telephone

I certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that false or misleading information given in my application or interview(s) may result in discharge. I agree to inform the District immediately if any of the information in this application changes. I also agree to inform the District immediately if there is a change in my motor vehicle record. I hereby authorize all my previous employers, or references to furnish any information concerning my personal character or employment records. I hereby release all such persons from liability or damages incurred as a result of inquiry and furnishing this information. If hired, I agree to furnish documentation within 72 hours showing my identity and that I am legally authorized to work in the United States.

In the event of employment, I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the District is of an "at will" nature, which means that the Employee may resign at any time and the District may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the District..

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

Signature ______________________________________________ Date _______________

I hereby certify, under penalty of perjury, that (please check only one)

____ I am not subject to a child support order

____ I am not more than 30 days delinquent in complying with a child support order

____ I am more than 30 days delinquent in complying with a child support order

AUTHORIZATION FOR MOTOR VEHICLE RECORD

The review of motor vehicle records and accident experience is important as past driving records affords one of the best clues to future performance as safe and dependable drivers. Past experience has shown there is a high correlation between poor driving records and accident frequency. It is the policy of NWMAD to review motor vehicle records and past accident experience of all applicants before granting employment and to review these records whenever an individual is involved in a motor vehicle accident.

Employment eligibility shall be based on the matrix illustrated below. In addition, applicants convicted of major violations are ineligible for employment at the District.

EMPLOYMENT ELIGIBILITY BASED ON MOTOR VEHICLE RECORD VIOLATIONS

Number of	Number Accidents During the Last 3 Years
Violations	0	1	2	3
0	Eligible	Eligible	Eligible	Non eligible
1	Eligible	Eligible	Eligible	Non eligible
2	Eligible	Eligible	Non eligible	Non eligible
3	Eligible	Eligible	Non eligible	Non eligible
4	Non eligible	Non eligible	Non eligible	Non eligible

Employees need to be rated "Eligible" to be considered for employment at the District. .

NOTE: The following are considered major violations:

DWI (alcohol or drug)	Refuse alcohol test	Illegal possession
Driving while impaired	Violation resulting in death	Revocation for a major violation
Failure to stop for an accident	Evade arrest	Misrepresentation to avoid arrest
26 MPH or more over posted	Revocation for habitual violator	Revocation for homicide
Revocation for manslaughter	Revocation for false statement	Revocation for felony
Revocation for all other	Reckless disregard	Operating without care
Driving to endanger life	Racing contest	Operating after license denied
Operating while suspended or	Revocation for financial	Vehicle used in connection with a
revoked	Responsibility	felony
Misrepresentation to obtain a	More than 1 speeding conviction 15-25	More than 1 moving violation in the
driver's license	MPH in the past 2 years	past 6 months prior to employment

NOTE: If a prospective employee provides the District with a court document amending his/her Motor Vehicle Report, eligibility will be reconsidered.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, (Public Law 91-508), as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that a department of motor vehicle report will be obtained on you for employment purposes.

I acknowledge the receipt of the above disclosure and authorize the above named company to obtain the department of motor vehicle report for employment purposes. This authorization is ongoing and permission is granted for the above listed company to secure this information during the course of my employment.

_______________________________________ ______________________

Applicants Signature Date

_____________________________

Print Name

Social Security Number __________________

Birth Date ____________________

Drivers License # _____________________________________ State issued _________

___________________________ __________________

Reviewer's Signature Date

(Sign and retain the original copy in the employee's file)

Please fax/mail the completed and signed application to (847) 537-2583