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DATE: POSITION: DEPT: APPLICATION FOR EMPLOYMENT CITY OF LEWISTON HUMAN RESOURCES DEPARTMENT CITY BUILDING 27 PINE STREET LEWISTON ME 04240 We deeply appreciate your interest in the City of Lewiston and assure you that we are sincerely interested in your qualifications for possible employment in a capacity commensurate with your education and training. The City of Lewiston is an Equal Opportunity employer and will not discriminate in any of its practices on the basis of race, color, religion, sex, marital status, physical or mental disability, age, ancestry, national origin, or veteran status unless based upon a bona fide occupational qualification. PERSONAL DATA NAME: LAST FIRST MIDDLE PRESENT ADDRESS: NUMBER STREET CITY STATE ZIP CODE TELEPHONE How long have you lived at the above address? PREVIOUS ADDRESS: NUMBER STREET CITY STATE ZIP CODE How long did you live there? Are you a legally authorized to work in the U.S.? YES NO In case of emergency notify: NAME RELATIONSHIP STREET ADDRESS CITY STATE ZIP CODE TELEPHONE # IF YOUR ANSWER IS “YES” TO QUESTION 1 OR 2 PLEASE EXPLAIN FULLY ON A SEPARATE SHEET OF PAPER. 1. Have you ever been convicted of a felony? YES NO 2. Can you perform the essential functions of the job for which you are applying? YES NO If NO, list reasonable accommodations required for you to perform the job: Do you possess a valid State of Maine driver’s license? YES NO If yes, give license number: Class: Endorsements: Have you ever been employed by the City of Lewiston? YES NO If yes, what department: When: MILITARY SERVICE RECORD Were you in the U.S. Armed Forces? YES NO If YES, what branch? Dates of duty: From: To: Rank at discharge: List duties in the service including special training: Do you possess an honorable discharge? YES NO ---PAGE BREAK--- CERTIFICATE OF APPLICANT (Please read carefully before signing). I hereby certify that all answers given in this application are true and accurate to the best of my knowledge. If employed, I real- ize that any false statements or omissions of material facts made by me during the application and employment process shall be considered sufficient cause for immediate dismissal. In making this application, I also understand that an investigative report may be made as to my character, reputation, ability, and credit record. SIGNATURE OF APPLICANT: DO NOT WRITE BELOW THIS LINE EXIT INTERVIEW COMMENTS: SIGNED: DATE: NAME & LOCATION OF SCHOOL COURSE OF STUDY LAST YEAR COMPLETED DID YOU GRADUATE? ELEMENTARY YES NO HIGH SCHOOL YES NO COLLEGE YES NO OTHER YES NO EDUCATION & TRAINING PREVIOUS EXPERIENCE COMPANY NAME & LOCA- TION (start w/most recent employer) DESCRIPTION OF DUTIES DATES SALARY REASON FOR LEAVING FROM: TO: $ FROM: TO: $ FROM: TO: $ List here any other qualifications or experience you may possess which you think is applicable to the position you are applying for (such as typing, shorthand, equipment you can operate, other languages you know, etc.). PERSONAL REFERENCES (Not former employers or relatives) NAME & OCCUPATION ADDRESS PHONE NUMBER 1. 2. 3. Print Form Clear Form