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Application for Employment 1338 Rumsey Ave. PO Box 2200 CODY, WY 82414 (307) 527-7511 NAME LAST FIRST MIDDLE LIST OTHER NAMES USED, IF MAILING ADDRESS STREET OR PO BOX CITY STATE ZIP CODE PRIMARY TELEPHONE NUMBER ( ) - ALTERNATE TELEPHONE NUMBER EMAIL Are you under the age of 14? YES NO Are you over the age of 18? YES NO (For Police Officers in WY, the minimum age is 21) Have you ever been employed by the City of Cody? YES NO If yes, give dates I understand, if hired, I will be required to provide proof of eligibility to work in the United States. YES NO Have you ever been convicted of any law violation other than a minor traffic violation? YES NO (“YES” answer does not automatically disqualify you from employment since the nature of the offense, date and the job for which you are applying will also be considered.) If yes, give details: Are you related to anyone presently working for the City of Cody? YES NO If Yes, list name Do you have a valid license? YES NO Driver’s License # STATE? Do you have a Commercial Driver’s License? YES NO Class: (A,B,C) Endorsements Held: Hazardous Material Tanker Airbrakes Passenger Have you ever been terminated, dismissed or asked to resign from any position? YES NO If yes, please explain Educational Background COLLEGE/UNIVERSITY/TRADE SCHOOLS CITY/STATE CREDITS COMPLETED DEGREE/ DIPLOMA YEAR MAJOR MINOR High School: City Website: http:// www.cit yofcody -wy.gov Email:[EMAIL REDACTED] RECYCLE CENTER WORKER 5 Year Driving Record must be submitted with Application POSITION APPLIED FOR DATE OF APPLICATION / / ---PAGE BREAK--- Employment History List your employment history starting with the most recent employer. List all positions held, including military experience, part-time, summer and/or volunteer work and periods of unemployment. Explain any gaps in employment in comments section below. EMPLOYER TELEPHONE ( ) - DATES EMPLOYED Summarize your job responsibilities FROM TO ADDRESS JOB TITLE SALARY FINAL IMMEDIATE SUPERVISOR AND TITLE $ PER HOUR PER WEEK PER MONTH REASON FOR LEAVING MAY WE CONTACT? EMPLOYER TELEPHONE ( ) - DATES EMPLOYED Summarize your job responsibilities FROM TO ADDRESS JOB TITLE SALARY FINAL IMMEDIATE SUPERVISOR AND TITLE $ PER HOUR PER WEEK PER MONTH REASON FOR LEAVING MAY WE CONTACT? EMPLOYER TELEPHONE ( ) - DATES EMPLOYED Summarize your job responsibilities FROM TO ADDRESS JOB TITLE SALARY FINAL IMMEDIATE SUPERVISOR AND TITLE $ PER HOUR PER WEEK PER MONTH REASON FOR LEAVING MAY WE CONTACT? Additional job history and/or resume can be attached. EXPLAIN GAPS IN EMPLOYMENT: SPECIAL SKILLS AND QUALIFICATIONS: Summarize special skills and qualifications you would like us to consider including certifications and licenses. Professional References List three (non-related) persons who can objectively assess your professional or scholastic performance. NAME TELEPHONE YEARS KNOWN ---PAGE BREAK--- CERTIFICATION OF ACCURACY & AUTHORIZATION TO RELEASE INFORMATION I certify that all information provided in this application is true and complete. I understand misrepresentation or omission of facts during the application or selection process may disqualify me from further consideration and may be cause for dismissal. I understand the City of Cody may conduct a background investigation, which may include obtaining information as to my character, reputation, and mode of living. This may include interviews with my relatives, neighbors, friends, former employers, schools and others. I authorize the City of Cody to investigate my employment background and personal history. I authorize the City of Cody to obtain any and all information relevant to determining my qualifications for the job for which I have applied. I further authorize the City of Cody to obtain copies of and review any and all employment records, documents and such other information as the City of Cody may determine relevant to its investigation. I agree to sign an authorization and consent to release of information to allow the City of Cody to obtain copies of prior employment records, documents and information from prior employers, organizations, references, and individuals who may have information relevant to my qualifications to work for the City of Cody. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that I may also be required to successfully pass drug and alcohol screening examinations. I hereby consent to pre- and/or post-employment drug and alcohol screens as a condition of employment, if required. I have read, understand, and by my signature, consent to these statements. I authorize investigation of all information contained in this application. Signature of Applicant Date Five Year Driving Record must be submitted with application to be considered for any positions with the Parks Division. Obtain this record from the DMV (Department of Motor Vehicle) ---PAGE BREAK--- City of Cody Provisional Position 5 year driving record requirement - Applicants applying for position(s) with the Sanitation Division are required to submit a 5-year driving record with application. Driving record can be obtained from the DMV. Recycling Division Job Title Rate of Pay Recycling Worker $10.12/hr . Must submit a Driving History Record with application. Recycling Worker - Jobs will include a variety of task associated with the following: Assist with the baler operation involving recycling of cardboard, aluminum, paper and plastic. Unload bins storing recyclables, relocate recyclables for baling. General maintenance duties include cleanup areas of Recycling Facility (sweeping, disposing of unusable materials) and Recycling Yard (moving recyclables, organizing materials, disposing of unusable materials, cleaning storage containers, etc). Assist with transporting recycling trailers from drop off locations within City limits to Recycling Center, unloading recyclables and transporting recycling trailers back to drop off locations. May be required to utilize fork lift, electric and/or hand tools. Tasks require a variety of physical actives generally involving muscular strain and hand-eye coordination. Physical demands may occur in activities related to walking, standing, stooping, sitting, reaching, lifting, pulling etc. Employee may interact with the public as necessary. Work schedule consists of three mornings - six hours on Monday, five hours on Tuesday and five hours on Fridays - weekly throughout the entire calendar year. Work schedule may be adjusted both in hours or day of week as needed. May assist other City divisions as assigned. Must be 18 years of age or older and have a valid driver’s license. Must submit a Driving History Record with application.