<p> 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</p><p>APPLICATION FOR EMPLOYMENT</p><p>Please TYPE or PRINT in black ink</p><p>Name ______Social Security No. ______(Last) (First) (Middle) </p><p>Mailing Address ______(Street) (City) (State) (Zip) Home Phone</p><p>______Work Phone</p><p>______</p><p>Title of job applying for ______When can you start? ______</p><p>Are you related to any one of the commissioners or anyone presently employed by the DISTRICT YES NO If “YES”, explain: ______</p><p>If hired can you present evidence that you can lawfully work in the United States? YES NO</p><p>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.</p><p>EDUCATION (Note: Applicants may be required to provide proof of diploma, degree, etc.)</p><p>Indicate Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12</p><p>Did you graduate High School Or receive a GED? YES NO</p><p>Please list all trade schools, military schooling, business colleges, etc.______</p><p>______</p><p>FORMER EMPLOYERS (List below the last three, starting with last one first)</p><p>Dates Name and address of Employer Salary Position Reason for Leaving</p><p>Page 1 of 4 REFERENCES (List the names of three people not related to you, whom you have known at least one year.)</p><p>Name Address Business Years Acquainted</p><p>IN CASE OF EMERGENCY NOTIFY</p><p>(Name) (Address) (Phone Number)</p><p>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.</p><p>Date: ______Signature: ______</p><p>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.</p><p>Please provide the following information as applicable:</p><p>____ 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. ______</p><p>____ Tractor w/ 6’ mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Tractor w/ slope mower First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Tractor w/ front-end loader bucket (attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Tractor w/ fork-lift (attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Tractor w/ ______(attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Dozer w/ blade First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Gradall, steel tracks First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ Link Belt, steel tracks long reach mower/bucket First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ ASV / ______(attachment) First / last year to operate was ______/ ______Operated for whom, ______Phone No. ______</p><p>____ 24’ Gooseneck Trailer (double axel tandem wheel) Explain type work performed: ______years’ experience</p><p>Page 3 of 4 ____ 18’ Utility Low-Boy Trailer (double axel single wheel) Explain type work performed: ______years’ experience</p><p>____ 8’ Utility Trailer (single axel) Explain type work performed: ______years’ experience</p><p>____ 18” Wood Chipper Explain type work performed: ______years’ experience</p><p>____ 500 gal. Chemical Spray Trailer Explain type work performed: ______years’ experience</p><p>____ Grade Instrument (Transit) Explain type work performed: ______years’ experience</p><p>List all other equipment (trucks, mowing, heavy and other) you may be operated. Please provide for whom equipment was operated and phone number.</p><p>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. </p>