Lee Walden, P.E. - President * Buddy Moore Vice President

BRAZORIA COUNTY DRAINAGE DISTRICT # 5 P.O. BOX 1 * ROSHARON, TX * 77583 * PHONE (281) 369-0071 * FAX (281) 595-3199 LEE WALDEN, P.E. - PRESIDENT * BUDDY MOORE – VICE PRESIDENT MARK ROLLER – SECRETARY/ TREASURER

APPLICATION FOR EMPLOYMENT

Please TYPE or PRINT in black ink

Name ______Social Security No. ______(Last) (First) (Middle)

Mailing Address ______(Street) (City) (State) (Zip) Home Phone

______Work Phone

______

Title of job applying for ______When can you start? ______

Are you related to any one of the commissioners or anyone presently employed by the DISTRICT YES NO If “YES”, explain: ______

If hired can you present evidence that you can lawfully work in the United States? YES NO

Have you ever been convicted of a felony or subjected to a deferred adjudication on a felony charge? YES NO If “Yes”, explain in concise detail on a separate sheet of paper, giving the dates and nature of the offense, the name and location of the court, and the disposition of the case(s). A conviction may not disqualify you, but a false state will.

EDUCATION (Note: Applicants may be required to provide proof of diploma, degree, etc.)

Indicate Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12

Did you graduate High School Or receive a GED? YES NO

Please list all trade schools, military schooling, business colleges, etc.______

______

FORMER EMPLOYERS (List below the last three, starting with last one first)

Dates Name and address of Employer Salary Position Reason for Leaving

of 4 REFERENCES (List the names of three people not related to you, whom you have known at least one year.)

Name Address Business Years Acquainted

IN CASE OF EMERGENCY NOTIFY

(Name) (Address) (Phone Number)

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINTED AT ANY TIME.

Date: ______Signature: ______

Brazoria County Drainage District No. 5 is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services.

Please provide the following information as applicable:

____ Tractor w/ 15’ batwing mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______Tractor w/ 10’ batwing mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Tractor w/ 6’ mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Tractor w/ slope mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Tractor w/ front-end loader bucket (attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Tractor w/ fork-lift (attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Tractor w/ ______(attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Dozer w/ blade First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Gradall, steel tracks First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ Link Belt, steel tracks long reach mower/bucket First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ ASV / ______(attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______

____ 24’ Gooseneck Trailer (double axel tandem wheel) Explain type work performed: ______years’ experience

of 4 ____ 18’ Utility Low-Boy Trailer (double axel single wheel) Explain type work performed: ______years’ experience

____ 8’ Utility Trailer (single axel) Explain type work performed: ______years’ experience

____ 18” Wood Chipper Explain type work performed: ______years’ experience

____ 500 gal. Chemical Spray Trailer Explain type work performed: ______years’ experience

____ Grade Instrument (Transit) Explain type work performed: ______years’ experience

List all other equipment (trucks, mowing, heavy and other) you may be operated. Please provide for whom equipment was operated and phone number.

Provide photocopy (front/back) of current State of Texas Driver’s License and any other State of Texas License (Texas Department of Agriculture and/or other) to operate any of the above and/or other equipment.