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APPLICATION FOR: VolunteerReceptionProgram Moscow Police Department 122 East Fourth St Moscow, 1083843 (208) 883-7054 Telephone (208) 882-4020 Fax Please Print or Type Position(s) applied for Referral Source: Date of application I I o Advertisement 0 Employee o Relative o Government Employment Agency o Walk-in o Private Employment Agency o Internet Web Site o Other Name of Source (if applicable) Name Last First Middle Address Street City State Zip Code Telephone Number { If necessary, best time to call you at home is am/pm May we contact you at work? 0 Yes 0 No Have you filed an application here before? 0 If Yes, give work number { Yes 0 No If yes, give date I I and position applied for: Have you ever been employed here before? Yes 0 No 0 If Yes, give dates Areyoulegallyeligiblefor employmentin thiscountry? 0 Yes 0 No Date available for work I I Are you on layoff and subject to recall? 0 Yes 0 No Are you able to meet the attendance requirements of the position? 0 Yes ONo Willyouworkovertimeif required?OYes 0 No Haveyoueverbeenbonded? OYes ONo Doyouhavea validdriverslicense(ifjob related)? OYes D No Haveyoubeenconvictedof a felonyinthe lastseven(7)years? DYes 0 No (suchconvictionmaybe relevantif job related,butdoesnot baryoufromemployment.) I I If Yes, please explain ---PAGE BREAK--- List your last four employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below. Comments (including explanation of any gaps in employment) Current Employer Telephone Dates Employed Summarize the nature of the work ( ) From To oerformed and job Address Job Title Salarv Starting Immediate Supervisor and Title $ per Reason for Leaving Salary Final May we contact for reference? Yes D No D LaterD $ per Employer Telephone Dates Employed Summarize the nature of the work ( ) From To performed and job Address Job Title Salarv Starting Immediate Supervisor and Title $ per Reason for Leaving Salary Final May we contact for reference? Yes D No DLater D $ per Employer Telephone Dates Employed Summarize the nature of the work ( ) From To performed and iob Address Job Title Salary Startina Immediate Supervisor and Title $ per Reason for Leaving Salary Final May we contact for reference? Yes D No D Later D $ per Employer Telephone Dates Employed Summarize the nature of the work ( ) From To performed and iob Address Job Title Salary Startina Immediate Supervisor and Title $ per Reason for Leaving Salary Final May we contact for reference? Yes D NoD LaterD $ per ---PAGE BREAK--- Ed A. List last three schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Major and minor field of study (if applicable). Ski II san d Qua Iifi cat ion s - Summarizeanytraining,skills,licenses,certificates,etc.that mayqualifyyou as beingableto performjob-relatedfunctionsof the positionfor whichyouareapplying. List name and telephone number of three business/work references who are not related to you and rvisors. If not applicable, list three school or personal references who are not related to you. Name Telephone Years K List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal gender, race, religion, national origin, age, color, disability or other protected status.) Organization Offices Held List special accomplishments, publications, awards, (exclude information which would reveal gender, race, religion, national origin, age, color, disability or other protected status.) List any additional information you would like us to consider. A. School B. Years C. Degree D. Major E. Minor Completed Completed ( ) ( ) ( ) ---PAGE BREAK--- It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the City of Moscow's service if I have been employed. I give the City of Moscow the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the City of Moscow and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. The City of Moscow is an Equal Opportunity Employer. The City of Moscow does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. I understand it is the City's policy not to refuse to hire a qualified individual because of this person's need for an accommodation that would be required by the ADA. Signature of Applicant Date / / All applicants will be notified following the review of all applications. Please do not call to find out if you have been selected for an interview.