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APPLICATION FOR EMPLOYMENT Human Resources Department City Hall 27 Pine Street, Lewiston ME 04240 The City of Lewiston is an Equal Opportunity Employer. The City of Lewiston does not discriminate in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral or any other aspect of employment on the basis of race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. The City of Lewiston does not discriminate against qualified applicants and employees with disabilities in hiring, promotion, discharge, pay, job training, fringe benefits, classification, referral or any other aspect of employment. The City of Lewiston also provides qualified applicants and employees with disabilities with reasonable accommodations that do not impose undue hardship on the City of Lewiston. PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY Last Name: First Name: Middle Initial: Cell Phone Home Phone Email Address: Home Address: City: State: Zip Code: How long have you lived at the above address: Have you ever been employed by the City of Lewiston, including the Lewiston School Department before? Yes No If Yes, Please list department and position: Are you 18 years or older: Yes No Are you prevented from lawfully becoming employed in the U.S. due to Visa or Immigration Status: Yes No (proof of citizenship or immigration status is required upon employment) Are you related to a City of Lewiston employee: Yes No If yes, list family member’s name and relation: Education & Training Name & Location of School # of Years Completed Diploma/Degree Type High School College Technical/Other Military Service Were you in the U.S. Armed Forces: Yes No If yes, which branch: Dates of Service: Rank at Discharge: Please list duties and training: Do you possess a valid Maine Driver’s License: Yes No License Exp. Date: License Class: Endorsements: Has your license, permit or privilege ever been suspended or revoked: Yes No ---PAGE BREAK--- 2 Employment History Company Name & Location (start with most recent employer) Position Held Dates Reason for Leaving Supervisor’s Name From: To: From: To: From: To: List any other qualifications or experience you possess which you think is applicable to the position you are applying for (Such as equipment you can operate, other languages you know, etc.). (Attach additional sheet or resume) Professional References (Cannot be a relative.) Name & Occupation Address Phone Number 1. 2. 3. CDL Drivers Only Accident Record for past three years: (attach additional sheet if more space is needed) Date of Accident Nature of Accident Location of Accident # of Fatalities # of People Injured Traffic Convictions and Forfeitures for the last three years (other than parking violations): Date Location Charge Penalty Driving Experience Class of Equipment From Date To Date Approximate Number of Miles Straight Truck Tractor & Semi trailer Tractor & Two Trailers Tractor & Triple Trailers Other Were you subject to (Federal Motor Carrier Safety Regulations) while working for a past employer? Yes No Were any of your past jobs designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? Yes No ---PAGE BREAK--- 3 Applicant’s Statement and Conditions of Employment Please read carefully before signing: “I certify that this application was completed by me and that the answers given by me in this employment application are true, correct and complete. I agree that the City of Lewiston (hereafter “the City”) shall not be liable, in any respect, if my employment is terminated because of misstatements or pertinent omissions made by me in the application. Moreover, I understand that all offers of employment are contingent upon passing the City’s prescribed physical examination and/or drug screen and background checks”. “I agree, as a condition of my employment (should I be employed by the City), to submit to a medical examination and/or drug screen paid for by the City based on the position that I accept. I also authorize any company, school, police or security personnel, or other pertinent person to give any information regarding my employment, habits, ability, or any other characteristics whatsoever; together with any information they have regarding me, whether or not it is in their records. I hereby release all physical examiners, companies, schools, or other persons from liability from any damages whatsoever for such testing, examining, or issuing this information. It is agreed and understood that completion of this application does not mean a job opening exists and in no way obligates the City to employ me”. “I understand that an investigative consumer report involving information concerning my character, employment history, general reputation, police record, personal habits, mode of living, credit and indebtedness may be obtained prior to any final offer of employment. I also agree and understand that per the Fair Credit Reporting Act, Public Law 91- 508, that this is my notice of investigation”. “I understand that nothing contained herein is intended to create a contract between the City and me for either employment or the provision of any compensation or benefits. I understand that if I am employed by the City I may be subject to a probationary period, during which time I may be terminated with or without cause”. “During my employment and after my employment with the City ends, I agree not to disclose any confidential information regarding the City’s operations or personnel. A copy of this form may be used as the original. The use of the results from this form and/or applicable test(s) will be used for prudent employment decisions”. This application is valid for sixty days from the application date unless renewed in person or in writing. Applicant’s Signature: Date: Position Applied for: Department: How did you hear about this position: SIGN