Announcement - ECS Joins Legacy Utility Group

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620.364.3105

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Employment Application

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Applicant Information
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Email
Date Available for Hire
Month
Day
Year
Desired Salary
Position applied for
Are you a citizen of the United States?
- Yes
- No
If no, are you authorized to work in U.S.?
- Yes
- No
Have you ever worked for this company?
- Yes
- No
If yes, when?
Have you been convicted of a felony?
- Yes
- No
If yes, explain:
Are you willing to travel?
- Yes
- No
Education
High School
Name of High School Address
Years Attended
From To
Did you graduate
- Yes
- No
Diploma
College
Name of College Address
Years Attended
From To
Did you graduate
- Yes
- No
Diploma
Other
Name of other Educational Institute Address
Years Attended
From To
Did you graduate
- Yes
- No
Diploma

References
Please list three professional references.
Reference 1
Full Name Address Company Phone Relationship
Reference 2
Full Name Address Company Phone Relationship
Reference 3
Full Name Address Company Phone Relationship
Previous Employment
Previous Employer 1
Company Address Phone Supervisor Job Title
Salary
Starting Salary $ Ending Salary $
Dates Employed
From To
Responsibilities
Reason for Leaving
May we contact your previous supervisor for a reference?
- Yes
- No
Previous Employer 2
Company Address Phone Supervisor Job Title
Dates Employed
From To
Salary
Starting Salary $ Ending Salary $
Responsibilities
Reason for Leaving
May we contact your previous supervisor for a reference?
- Yes
- No
Previous Employer 3
Company Address Phone Supervisor Job Title
Dates Employed
From To
Salary
Starting Salary $ Ending Salary $
Responsibilities
Reason for Leaving
May we contact your previous supervisor for a reference?
- Yes
- No
Military Service
Service Info
Branch Rank at Discharge From To
Type of Discharge
If other than honorable, please explain

Voluntary Affirmative Action Information
Completion of this page is voluntary. You may skip this page and still be considered for a position. Qualified applicants are considered for employment without regard to race, color, religion, sex, national origin, age, sexual orientation, marital status, veteran status, medical condition, disability or any other protected class. In an effort to comply with requirements regarding government recordkeeping, reporting, and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated. Please be advised that this survey is NOT a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision. Upon receipt it is filed separately from the employment application.
Applicant Info
Name Position applied for Date
Referral Source
- Newspaper Advertisement
- Magazine Advertisement
- Government Employment Agency
- Walk-in
- Web Site
- Job Fair
- Employee/Relative
- Private Employment Agency
- I do not wish to Self-Identify
Sex
- Male
- Female
Age
- Under 18
- Over 40
Race/Ethnic Group
- Black/African American: All persons having origins in any of the Black racial groups of Africa
- Hispanic/Latino: All persons Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture regardless of race
- Asian: All person having origins in any of the original people of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, The Philippine Islands, and Samoa.
- Native American: All persons having origins in any of the original people of North America, and who maintain cultural identification through tribal affiliation or community recognition. (Meets Bureau of Indian Affairs definition standards)
- Two or more races: Not Hispanic or Latino
- White: (or not covered above)
Check one, if applicable
- Veteran
- Vietnam Era Veteran
- Current Military
- Current Military Reserves
- Disabled Veteran
- Individual with a disability

Disclaimer and Signature
I certify that the above is true and correct.*
Name Date

ECS, Inc. Home Office

310 Congress

Emporia, Kansas 66801

620.364.3105

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