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APPLICATION FOR EMPLOYMENT Title and Position Number for which you are applying: Job Title Position Number CITY OF FARMINGTON PERSONNEL DEPARTMENT 850 Municipal Drive Farmington, New Mexico 87401-2663 Telephone: (505) 599-1132 email: [EMAIL REDACTED] website: http://www.cofjobs.com PLEASE READ THIS BEFORE FILLING OUT THE APPLICATION FORM A new application must be submitted for each position for which you are applying. Resumes are not accepted in lieu of an application, but may be attached for supplemental information. The completed application may be submitted to the Personnel Office at 850 Municipal Drive or via email to [EMAIL REDACTED]. This application form is an important part of the employment process. Candidates for any position may be eliminated based on an evaluation of the application. Please type or complete in ink as neatly and clearly as possible. Answer all questions to the best of your knowledge. You may provide as much detail as you wish by adding extra sheets of information or a resume. False, incomplete or inaccurate information is cause for disqualification or discharge. Thank you for your interest in our City. If you need assistance completing this application, contact the Personnel Office at (505) 599-1132. PERSONAL INFORMATION Name: Last First M.I. Present Mailing Address: Number and Street City State Zip Code Street Address, if different from above: Telephone Number: (circle one) Home or cell: Business/Message: May we communicate with you via e-mail? Yes No If yes, print e-mail address: Do you have a valid Drivers License? Yes No Additional information will be required prior to employment. GENERAL INFORMATION Can you work legally in the United States? Yes No If hired, documentation showing eligibility for employment in the United States and identity will be required. Have you ever been employed by the City of Farmington? Yes No If "yes", on a separate sheet please give date(s), job title(s).department location(s) and reason(s) for separation. ---PAGE BREAK--- R E C O R D O F E D U C A T I O N School Name and Address of School Course of Study Last Year Completed Did you Graduate List Diploma or Degree High 1 2 3 4 Yes No College 1 2 3 4 Yes No College 1 2 3 4 Yes No Other Specify 1 2 3 4 Yes No M I L I T A R Y S E R V I C E R E C O R D Have you served in the U.S. Military Service? Yes No If yes, list skills acquired, including special training: E M P L O Y M E N T E X P E R I E N C E List below all present and past employment beginning with your most recent. If you held more than one position with the same employer, please list each position separately. Employer From Month/Year To Month/Year Work Performed Street Address City State Phone Number of Employer Job Title Supervisor Reason for Leaving 1 ---PAGE BREAK--- Employer From Month/Year To Month/Year Work Performed Street Address City State Phone Number of Employer Job Title Supervisor Reason for Leaving Employer From Month/Year To Month/Year Work Performed Street Address City State Phone Number of Employer Job Title Supervisor Reason for Leaving Employer From Month/Year To Month/Year Work Performed Street Address City State Phone Number of Employer Job Title Supervisor Reason for Leaving Employer From Month/Year To Month/Year Work Performed Street Address City State Phone Number of Employer Job Title Supervisor Reason for Leaving 3 2 3 4 4 5 ---PAGE BREAK--- Other Licenses or Certifications (if required for the job): Profession Trade: Level: Expiration Date: Issued By: Summarize any special skills or qualifications. Include knowledge, skills and abilities not shown elsewhere in this application. Be specific. Any offer of employment may be made contingent on applicant passing a job related physical examination and drug test. It is the policy of the City to avoid both the practice and the appearance of nepotism in employment. In carrying out this policy, no person shall be hired to a position which is under the supervision of a relative. No person who is related to the City of Farmington Mayor, City Councilors, or City Manager shall be hired to any position. If any of your relatives are employees or elected officials of the City of Farmington, please list their name and family relationship to you: Name Department Relationship Name Department Relationship EMERGENCY CONTACT: Name Address Phone A G R E E M E N T A N D C O N S E N T 1. I certify that these answers are true and correct to the best of my knowledge. 2. I UNDERSTAND THIS APPLICATION IS SUBJECT TO VERIFICATION. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN. I understand that misrepresentations or omissions of fact in this application will be sufficient cause for disqualification or dismissal from employment with the City of Farmington if I have been employed. I agree that the City of Farmington will not be held liable in any respect if any employment offer is not tendered, is withdrawn, or my employment is terminated due to false statements and answers in this application. I understand and agree that this application is an initial application. I understand that additional information may be required of me. I further understand and agree that this paragraph applies to any information supplied by me at a later date as part of this application. 3. I understand that this application may be a public record and, upon request, may be released by the City of Farmington, as required by law. 4. I hereby acknowledge that I have read and agree to the above statements. Your Name. Filling in this field constitutes an electronic signature. Date We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, or any other legally protected status. We are an Equal Opportunity Employer, M/F. October 2010 The City of Farmington is a Drug and Alcohol Free Workplace ---PAGE BREAK--- VOLUNTARY COMPLETION BY APPLICANT. NOT FOR INTERVIEW PURPOSES. This section of the application will be separated from the employment application when it is received by the Personnel Office. The information provided will have no bearing upon your consideration for employment. The information is ONLY used to assist us in complying with Federal Equal Employment Opportunity record keeping and reporting requirements. The City of Farmington does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, or any other legally protected class in employment or the provision of services. FAILURE TO SUPPLY THIS INFORMATION WILL NOT JEOPARDIZE OR ADVERSELY AFFECT ANY CONSIDERATION YOU MAY RECEIVE FOR EMPLOYMENT OR LATER ADVANCEMENT OR RE-EMPLOYMENT. Date: Position Applied For: Position Name: SSN: Sex: Male Female Veteran of Vietnam-era: Yes No VETERAN of the VIETNAM-ERA means a veteran, any part of whose active military, naval, or air service, was during the period August 5, 1964 through May 7, 1975 who served on active duty for a period of more than 180 days and was discharged or released therefrom with other than a dishonorable discharge, or (ii) was discharged or released from active duty because of a service-connected disability. CHOOSE the ethnic group with which you most closely identify and mark the box provided. White Black Hispanic American Indian or Alaskan Native Asian or Pacific Islander White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Black: A person having origins in any of the black racial groups of Africa. Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. American Indian or Alaskan Native: A person having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.