1557 FM ROAD 1110 ▪ CLINT, TX 79836 ▪ (915)791-4480 ▪ (915)791-4498 FAX

Employees of the Lower Valley Water District and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age. In addition, equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.


* Position applying for: *Date:
* Name (Last, First, Middle): * Telephone Number:
Address: Alternate Phone Number:
City/State/Zip Code: *Email Address:


If you did not complete high school, do you have a high school equivalency diploma?
Name and Location of Institution Years Completed Major Field of Study
Degree Received
High School

Work Experience
Last Job

Company: Last Supervisor:
Start Date: End Date:
Phone Number: Your Last Job Title:
Reason for leaving (be specific): May we contact this employer?

Work Experience
Last Job 2

Company: Last Supervisor:
Start Date: End Date:
Phone Number: Your Last Job Title:
Reason for leaving (be specific): May we contact this employer?


List names, addresses and relationships of three persons not related to you who know your qualifications. If not applicable, list three school or personal references that are not related to you.
Name: Address: Phone: Relationship:


Do you know or are you related to anyone at the Lower Valley Water District or the Lower Valley Water District Board of Directors?
If yes, whom?   
When will you be available to start work?

For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?

Under the Immigration Reform and Control Act of 1996, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identify. Further, you will be required to provide documentation to that effect should you be employed.
If you are under 18, and it is required, can you furnish a work permit?


Lower Valley Water District (“LVWD”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include a criminal records check, information about your character, general reputation, credentials, credit history, personal characteristics, driving record, and/or mode of living and which can involve personal interviews with sources such as your current and past employers, friends, or associates. In addition, LVWD may verify if you are a current or former LVWD customer in good standing. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. The scope of this notice and authorization is all-encompassing and allows Lower Valley Water District to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
Have you ever been convicted* for any violation(s) of law, including moving traffic violations?

If YES, please explain :

Statute or ordinance (if known):   
Date of Charge:                            
Date of Conviction::                       
County, City, State of Conviction:  

Each Application Requires Current Date and Original Signature

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Applicant Signature: Date: