Application For Employment (Page 5 of 5) in pdf

Applicant’s Statement

Please read carefully before signing.

I hereby affirm that the information provided on this Application and accompanying resume (if any) is true and correct to the

best of my knowledge. I also agree that any falsified information or significant omission may disqualify me from further

consideration for employment and may result in my discharge if discovered at a later date. I agree that the Public Utility

Commission shall not be liable in any respect if my employment is terminated because of false statements, answers or omissions.

I authorize the Public Utility Commission to investigate all statements made in this Application, contained in my resume or

made by me in any interview or other document. I authorize the Public Utility Commission to contact my current or most recent

employer for employment verification. I authorize the Public Utility Commission to investigate all statements in this Application

and to secure any necessary information from employers, references, educational institutions and certifying entities. I hereby release

these employers, references, educational institutions and certifying entities from any and all liability arising from their giving or

receiving information regarding my employment history, academic credentials or qualifications, and/or my

suitability for employment.

I understand that I may receive a job offer which is conditioned upon demonstration of my ability to perform the essential

functions of the position for which I have applied.

I understand that this Application will be considered active for a period of one hundred and twenty (120) days. Should I wish

to be considered for employment beyond this period of time, I acknowledge that I must complete another application form or

request in writing that my application continue to be considered.

Signature _____________________________________________

Date ________/_______/________

For Commonwealth Employees Only

I authorize the Public Utility Commission to review my Official Personnel Folder in the Department

of _____________________________________. My Employee Number is __________________________

Signature _____________________________________________

Date ________/_______/________

The Public Utility Commission is an equal opportunity employer dedicated to a policy of nondiscrimination in employment with-

out regard to race, color, religion, creed, gender, national origin, age, physical and/or mental disability, ancestry, pregnancy,

marital, veteran, or any other legally protected status. We value the contribution that the diversity of applicants can bring to the Public

Utility Commission. If you require assistance or a reasonable accommodation in completing this application or any aspect of the

application process, including interviewing, please contact the Human Resources Office.

Application For Employment Page 5