Full Text
AN EQUAL OPPORTUNITY EMPLOYER PLEASE PRINT Position(s) Applied For Date / / Name Last First Middle Address Street City State Zip Mailing Address (if different) Telephone # ( ) Alternate # ( ) E-mail Address Social Security # - - Valid Drivers License # State: Class: Check the types of employment you would accept: Full-Time Part-Time Temporary Seasonal Date Available For Work: Referral Source (How did you hear about us?) Have you ever been or are you presently employed by the City of Yes No If presently employed, are you seeking a: Promotion Voluntary Demotion Transfer Do you have relatives employed by the City of Yes No If “Yes,” in which department: Have you ever pleaded “guilty” or “no contest to,” or been convicted of a Yes No If “Yes,” please provide details: (An answer of “Yes” to this question does not constitute an automatic bar to employment. Attach additional sheet if necessary.) FOR SWORN POLICE DEPARTMENT POSITIONS: Do you certify that you have never in your adult life been convicted of, or pled no-contest to, a charge involving domestic violence? Yes No MILITARY SERVICE RECORD: Branch of service Dates Type of discharge Please review the minimum qualifications for a job before you apply. Be sure to include any supporting documents required in the announcement. Applications must be submitted by the final filing date on the announcement (except for continuous recruitment jobs.) DO NOT substitute a resume for this application form. Incomplete or illegible applications will not be processed. If a particular question is not applicable, write in the space. If more space is needed to give full answers or explanations, attach additional sheets. This application form and all attached documents are official records of the City of Douglas and cannot be returned or re-used. The information provided is considered confidential and will be used to evaluate your qualifications for employment. For Office Use Only Date Received: Short Form App. Implemented Aug 2008 City of Douglas Phone: [PHONE REDACTED] 101 N. 4th St. • P.O. Box 1030 FAX: [PHONE REDACTED] Douglas, WY 82633 www.cityofdouglas.org Application for Employment Skills and Qualifications List other job related courses or training, (trade, vocational, armed forces, business). Give name and location of each school/workshop/military service; dates attended and subjects studied. Also list additional college courses and number of semester or quarter hours taken which are specifically job related. Also list other job related qualifications, achievements, skills with machines, patents, publications, typing or keyboarding speed, professional licenses, etc. (give numbers and expiration dates of licenses). Attach additional sheets or transcripts if necessary. High School College / University / Trade School / Other Educational Background School (include City & State) Credits Completed S = Semester Q = Quarter Completed Major/Minor Dates Diploma GED Other Diploma Degree Certification Other Diploma Degree Certification Other Diploma Degree Certification Other References List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. Name Title Relationship to You Telephone Number of Years Known ( ) ( ) ( ) ---PAGE BREAK--- IMPORTANT INSTRUCTIONS FOR COMPLETING WORK HISTORY: List your entire work history part-time, temporary, volunteer, summer jobs and service in the armed forces. List your jobs starting with your present or most recent employer. List each promotion as a separate job. To evaluate your qualifications, we must have accurate and complete information on previous job tasks and levels of responsibility. DO NOT substitute a resume for specifics of tasks performed. For each job, list the most important or major tasks first (those which took up most of your time or were Employment History Applicant Statement I certify that all information provided by me in making application (or any other accompanying required documents) contains no willful misrepresentations, falsifications or omissions and that the information given by me is true, correct and complete to the best of my knowledge. I understand that falsification, misrepresentation or omission of any facts on this application shall be considered sufficient cause for denial of employment or if employed, immediate termination of employment, regardless of the timing or circum- stances of discovery. I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to the City of Douglas and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that if offered a position with the City of Douglas, I may be required to submit to a pre-employment medical examination, alcohol and drug screening and a back- ground check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS. Signature of Applicant Date / / Commission / Bonus / Other Compensation $ Commission / Bonus / Other Compensation $ Compensation (Final) Compensation (Start) Hourly Salary $ Hourly Salary $ Employer Telephone # Month Year Month Year ( ) Dates employed: / to / Street address City State Zip Position Held Full-Time Part-Time Other Supervisor May we contact for reference? Yes No Number and type of position supervised Reason for leaving Summarize tasks performed and job responsibilities: Average # of hours worked per week: Commission / Bonus / Other Compensation $ Commission / Bonus / Other Compensation $ Compensation (Final) Compensation (Start) Hourly Salary $ Hourly Salary $ Employer Telephone # Month Year Month Year ( ) Dates employed: / to / Street address City State Zip Position Held Full-Time Part-Time Other Supervisor May we contact for reference? Yes No Number and type of position supervised Reason for leaving Summarize tasks performed and job responsibilities: Average # of hours worked per week: Commission / Bonus / Other Compensation $ Commission / Bonus / Other Compensation $ Compensation (Final) Compensation (Start) Hourly Salary $ Hourly Salary $ Employer Telephone # Month Year Month Year ( ) Dates employed: / to / Street address City State Zip Position Held Full-Time Part-Time Other Supervisor May we contact for reference? Yes No Number and type of position supervised Reason for leaving Summarize tasks performed and job responsibilities: Average # of hours worked per week: Commission / Bonus / Other Compensation $ Commission / Bonus / Other Compensation $ Compensation (Final) Compensation (Start) Hourly Salary $ Hourly Salary $ Employer Telephone # Month Year Month Year ( ) Dates employed: / to / Street address City State Zip Position Held Full-Time Part-Time Other Supervisor May we contact for reference? Yes No Number and type of position supervised Reason for leaving Summarize tasks performed and job responsibilities: Average # of hours worked per week: SIGN