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WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES City of Burley Application for Employment We consider applicants for all positions without regard of race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. Position Applied For Date of Application How Did You Learn About Us Advertisement Relative Inquiry Web Site Friend Other Last Name First Name Middle Name or Initial Address City State Zip Code Telephone Number Cell Phone Number Email Address How would you like to be contacted: Cell Text Email Other Have you ever been employed with us before? Yes No If yes, give date Do any of your relatives, or anyone in a spousal type relationship, work for the City of Burley? Yes No If yes, who is the relation and how is the relative related to you? Are you currently employed? Yes No May we contact your present employer? Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment Yes No Date available for work What is your desired salary range? Are you available to work: Full Time Part-Time please indicate Mornings Afternoons Evenings Temporary please indicate dates available Are you currently on “lay-off” status and subject to recall? Yes No Can you travel if a job requires it? Yes No ---PAGE BREAK--- WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES EDUCATION Name and Location of School Course of Study No. of Years Completed Diploma Degree High School Yes No Undergraduate College Yes No Graduate Professional Yes No Other (Specify) Yes No Describe any specialized training, apprenticeships, skills and extra-curricular activities. Are you a Veteran or family member who qualifies for and are claiming a preference pursuant to Idaho code 365-503 or its successor? Yes No If yes, please complete the attached page entitled “Veteran’s Preference.” Branch of Military: Duties: Honorable Discharge Date: Describe any training directly related to the job you are applying for. Criminal History Have you ever been convicted of a misdemeanor or felony? Yes No If yes explain. ---PAGE BREAK--- WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES EMPLOYMENT EXPERIENCE Start with your present or last job. Please complete each area. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. Employer Work Performed Dates Employed From To Address Telephone Numbers Hourly Rate/Salary Starting Final Job Title Supervisor Reason for Leaving Employer Work Performed Dates Employed From To Address Telephone Numbers Hourly Rate/Salary Starting Final Job Title Supervisor Reason for Leaving Employer Work Performed Dates Employed From To Address Telephone Numbers Hourly Rate/Salary Starting Final Job Title Supervisor Reason for Leaving Employer Work Performed Dates Employed From To Address Telephone Numbers Hourly Rate/Salary Starting Final Job Title Supervisor Reason for Leaving Criminal History Have you ever been convicted of a misdemeanor or felony? Yes No If yes, explain List professional, trade, business or civic activities and offices held. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. If you need additional space, please continue on a separate sheet of paper. ---PAGE BREAK--- WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES REFERENCES REFERENCES APPLICANT’S STATEMENT If there are any other documents or information that you would like us to consider please attach to this application. 1. (Name) Phone # 2. (Name) Phone # 3. (Name) Phone # I certify that the information given herein is true and complete. I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision and I have signed the attached page entitled “Authorization for Release of Personal Information.” I authorize any background investigation as deemed appropriate by the City of Burley. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any Employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. Employer may discharge an employee with or without a written document. I understand that I am subject to pre-employment drug testing and failure of a drug test will eliminate my opportunity for employment. I certify that I have a valid drivers license issued by the state of Idaho or that I can obtain one within 30 days. In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge, I understand, also, that I am required to abide by all rules and regulations of the employer. I understand that if I am offered employment it is required that I have a pre-employment physical by a medical professional determined by the City of Burley. Signature of Applicant Date SIGN ---PAGE BREAK--- WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I, an applicant for employment with the City of Burley, do hereby authorize a review of and full disclosure of all records or information concerning myself to any duly authorize agent of the City of Burley, whether the said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of all records and information of educational institutions; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, either criminal or civil, in which I have, or have had any interest or involvement. I understand that any information obtained during any personal history background investigation which is developed directly or indirectly, in whole or in part, upon this authorization will be considered in determining my suitability for employment by the City of Burley. I hereby agree that any person(s) or entities who may furnish such information concerning me shall not be held liable for providing this information; and I do hereby release said person(s) and entities from any and all liability which may be incurred as a result of furnishing such information. I further authorize that a photocopy of this signed release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. DATED: Printed Name, including all names I have previously used or been known by: SIGN ---PAGE BREAK--- WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES VETERAN’S PREFERENCE If you are NOT claiming Veteran’s Preference, please initial here and proceed to the next page. Per Idaho Code, Title 65, Chapter 5, Employer will afford a preference to employment of veterans. In the event of equal qualifications and experience between candidates for an available position, a veteran who qualifies will be preferred. If claiming veteran’s preference, please complete the information below and attach a copy of your DD-214 to this application. (Reference Idaho Code, Title 65, Chapter 5, and 5 U.S.C. § 2108) The term “active duty” means full-time duty in the Armed Forces, but NOT active duty for training. Part 1. Preference Eligible Veterans: I have a service-connected disability of 10% or more. I am the spouse of an eligible disabled veteran, who has a service-connected disability. I am the widow or widower of an eligible veteran and have remained unmarried. I do not meet any of the selections above, but I served on active duty in the armed forces of the United States for a period of more than one-hundred eighty (180) days and was honorably discharged. Part 2. Documentation & Signature: By my signature, I certify that all statements on this form are true and complete to the best of my knowledge. I understand that should an investigation disclose inaccurate or misleading answers, my application may be rejected and my name removed from consideration for employment with Employer. I have attached a copy of my DD-214. Veteran’s preference will not be considered without this document. Name (Please Print) Signature DATE: SIGN