Full Text
1 EMPLOYMENT APPLICATION Date: Position applied for: Note: it is to your advantage to answer all questions on this application. (Please print neatly or type.) Name: Last First Middle Initial Social Security Number: Telephone Number: Cell phone (optional): email: Address: Street City State Zip To facilitate reference checks, please indicate any other name under which you have been employed: YES NO Date: from to Department: Have you worked for the City of Gilbert before? If yes, please complete the following information: Position(s) held: Reason for leaving: Do you have any relatives who work with the City of Gilbert? YES NO Name(s) & Relationship: Have you been given a copy of the job description or had the requirements of the job explained to you? YES NO Do you understand the requirements of the job? YES NO Can you perform the requirements of this job with or without a reasonable accommodation? YES NO If the job requires, do you have the appropriate valid driver’s license? YES NO Type State Expiration date NO Branch of Service: Are you a United States Military Veteran? YES Dates of Military Service: from to Those wishing to claim Veteran’s preference must submit Proof of Service Form DD214 at time of interview. City of Gilbert An Equal Opportunity Employer 105 SE 2nd Street PO Box 29 Gilbert, IA 50105 Phone: (515) 233-2670 ---PAGE BREAK--- 2 EDUCATION Circle highest grade completed: College: Institution Course of Study Degree Attained High School Diploma/GED Location of School College Attended Location of College College Attended Location of College List any additional training – work shops, volunteer work, etc., you have received that makes you more qualified for this position. Which of the required skills in the job announcement do you possess? What equipment can you operate? Do you have any other experience or qualifications not already listed that relate to the job applied for? Have you ever been convicted of a felony? (For the purpose of this question “convicted” includes found guilty, plead guilty, plead no contest or been given a deferred sentence or judgment) YES NO If Yes please explain, please include the facts of your case, the felony you were convicted for and how long ago. (Note: A conviction will not automatically disqualify an applicant for a job. The type and seriousness of the crime, the frequency of violations, the date of convictions, and the applicant’s entire work and educational history will all be considered.) Choose One Choose One ---PAGE BREAK--- 3 EMPLOYMENT HISTORY Start with your present or last job and include at least your last five years of work records. Please fill out this section carefully and completely, as you are only given credit for jobs you list and the dates you include. Please attach an additional sheet if you need more space. Include military experience and describe any major duty assignments. Include periods of self-employment. Give details of supervisory positions you may have had. If you are currently employed, may we contact your present employer? YES NO (circle one) Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: ---PAGE BREAK--- 4 Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: Employed by: Telephone Number: Address: Supervisor’s Name: Job Title: Duties: Employed from: (mo/year) To: (mo/year) Starting Salary: Final Salary: Hours per week: Reason for leaving: What date would you be available to begin work? NOTE: All applicants will be required to pass a pre-employment drug and alcohol screen and physical evaluation after being offered a position and beginning as an employee of the City of Gilbert. I attest that all statements on this application are true and correct. I understand that intentionally false statements made on this application will eliminate me from further consideration for employment or will be grounds for dismissal. I authorize the City of Gilbert and my previous employers (with the exception of ) to conduct or participate in an investigation of my personal background, work history and police record as may be necessary to verify the information provided in my employment application and to determine my fitness to hold the position for which I have applied. Applicant Signature Date SIGN ---PAGE BREAK--- 5 FOR PERSONNEL DEPARMENT USE ONLY Reviewed by: Position considered for / Referral to: