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Job Application

"*" indicates required fields

Step 1 of 7

14%

Date*

MM slash DD slash YYYY

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Please list any other names you have used (alias)

Other addresses you have lived in the past three years (1)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other addresses you have lived in the past three years (2)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other addresses you have lived in the past three years (3)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you legally authorized to work in the United States?*

Yes

No

Can you provide proof of eligibility to work?*

Yes

No

Rate of pay expected?*

When can you start?*

May we contact your previous employer?*

Yes

No

If no, please explain

Education

High School*

Field of Study (ex. college prep., vo-ag, business, electrical, carpentry)*

Years completed*

Graduated*

Yes

No

College, Trade or Business School, Etc.

Field of Study

Years completed

Graduated

Yes

No

Please note any additional training/experience you have.

Well Drilling

Plumbing

Welding

Forklift

Electrical

Truck Repair

Water Treatment

Hazardous Materials

Office Skills

Position(s) applying for*

Air Rotary Driller

Water Treatment Technician

Geotechnical Driller

Drillers Helper

Pump Technician

Lead Generator

Office Position

Unknown

Do you have any physical condition which may limit your ability to perform the job applied for?*

Yes

No

If yes, explain

Are you physically capable of heavy manual work (for driller, pump & treatment positions)?

Yes

No

Do you have a valid medical card to drive vehicles over 10,001 lbs?

Yes

No

If yes, Exp date

Would you be willing to take a physical examination? (required for drivers of all company vehicles)*

Yes

No

Driving History: Have you had any accidents in the past 3 years?

Last Accident - Date

MM slash DD slash YYYY

Nature (head on, rear-end, etc.)

Citation issued

Fatalities or injuries

Next Previous - Date

MM slash DD slash YYYY

Nature (head on, rear-end, etc.)

Citation issued

Fatalities or injuries

Next Previous - Date

MM slash DD slash YYYY

Nature (head on, rear-end, etc.)

Citation issued

Fatalities or injuries

Next Previous - Date

MM slash DD slash YYYY

Nature (head on, rear-end, etc.)

Citation issued

Fatalities or injuries

Next Previous - Date

MM slash DD slash YYYY

Nature (head on, rear-end, etc.)

Citation issued

Fatalities or injuries

List Traffic Convictions and License Forfeitures for the past 3 years (other than parking violations)

1. Date

MM slash DD slash YYYY

Location

Charge

Penalty

2. Date

MM slash DD slash YYYY

Location

Charge

Penalty

3. Date

MM slash DD slash YYYY

Location

Charge

Penalty

4. Date

MM slash DD slash YYYY

Location

Charge

Penalty

Driving Information

Driver License #*

State*

Expiration Date*

Class*

Endorsements

Restrictions

Is your driver’s license currently valid?*

Yes

No

Are you over the age of 21 (required for interstate CDL drivers)?

Yes

No

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

No

If yes, please describe all facts and circumstances

Has any license, permit or privilege ever been suspended or revoked?

Yes

No

If yes, please describe all facts and circumstances

Type of Equipment Driven

1. Type

Date (from)

MM slash DD slash YYYY

Date (to)

MM slash DD slash YYYY

2. Type

Date (from)

MM slash DD slash YYYY

Date (to)

MM slash DD slash YYYY

3. Type

Date (from)

MM slash DD slash YYYY

Date (to)

MM slash DD slash YYYY

Employment History - Please list information of all employers during the preceding ten years. List most recent position first.

1. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

2. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Employment Date From

MM slash DD slash YYYY

Employment Date To

MM slash DD slash YYYY

3. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Employment Date From

MM slash DD slash YYYY

Employment Date To

MM slash DD slash YYYY

4. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

5. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

6. Name

Address

Job Title

Supervisor Name

Supervisor Phone Number

Work Performed

Reason for Leaving

Pay Rate Start

Pay Rate Final

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

Upload Resume

Max. file size: 1 MB.

ACKNOWLEDGEMENTS*

I agree to these terms.

ALL APPLICANTS
I affirm that the information provided on this application or in connection with the processing of this application
(and any resume or other accompanying documents) is true and complete to the best of my knowledge. I
understand that if employed, false statements, significant omissions, or misleading information regardless of
when discovered, made on or in connection with my application and accompanying documents may result in
dismissal.
I authorize investigation of all statements contained in this application (and any resume or accompanying
documents) as may be necessary in arriving at an employment decision.
I understand that my prior employers may be contacted for the purpose of investigating my background as
required by 49CFR391.23.
I authorize all personnel, schools, companies, corporations, credit bureaus, and law enforcement agencies to
supply any and all pertinent information and release the same from any liability resulting from providing such
information.
I understand that from time to time the company may be asked to submit/release certain information, including
but not limited to, my employment or application for employment. I release the company and its agents from any
liability resulting from submitting/releasing such information.
I acknowledge that the company may request, as a condition of any offer of employment that is made or for
continued employment, that I undergo a medical exam, drug and alcohol testing, and I consent and agree to any
such exam, if required now or in the future. I understand that when drug testing is required, a satisfactory result
may be a condition of employment.
I understand that federal law prohibits the employment of unauthorized aliens and requires satisfactory proof of
employment authorization and identity inspection. All persons hired must submit satisfactory proof of
employment authorization and identity. Please have necessary documents available for inspection as required
by law.
If employed, I agree to abide by the rules and regulations of the company.
I understand that if I am employed, my employment is for no fixed period and is at-will. I understand that I could
be terminated at any time for any or no reason and I understand that I may quit at any time for any or no reason.
This understanding cannot be altered by anyone unless it is in writing and signed by the owner of the company.
I understand that this application does not create an offer of employment.
I understand that this company is an Equal Opportunity Employer.
This certifies that this application was completed by me, and that all entries on it and information in it are true
and complete to the best of my knowledge.
I have read and understand the above notice.

Phone

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Coastal Water
2963 S Military Hwy
Chesapeake, VA 23323
(757) 485-5217

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Coastal Water a Subsidiary of Negley’s Water