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MURRAY CITY CORPORATION APPLICATION FOR EMPLOYMENT POSITION FOR WHICH YOU ARE APPLYING: Name: Home Phone: Address: Cell Phone: City, State: Zip: Business Phone: Email Address: Type of Employment Desired 9 Full Time 9 Part Time 9 Seasonal/Summer Salary Expected Date Available for Work If hired, will you be able to work during the days and hours required for the position for which you are applying? Yes No If no, please explain: If hired, can you furnish proof that you are at least 18 years of age? Yes No Do you have a legal right to work in the United States? Yes No Have you ever been convicted of violating any law, other than a minor traffic violation? Yes No (Criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.) If yes, provide date, location and explain: Have you ever been discharged or forced to resign from a position? Yes No If yes, please explain fully: Do you have any experience from your military service that would be relevant to the job you are applying for? Yes No. If yes, please explain: To your knowledge, can you successfully perform the essential functions of the job you are applying for with or without reasonable accommodation? Yes No. List any relatives who are currently employed by Murray City: An Equal Opportunity • Affirmative Action Employer ---PAGE BREAK--- IMPORTANT INFORMATION Take time to fill in this section carefully and completely. The information you give will be used to determine your qualifications for employment. It is important that you answer all questions on your application fully and accurately; failure to do so may delay its consideration and could mean loss of employment opportunities. Your placement on a job register will be determined by one or a combination of the following: a rating of training and/or experience, an oral or written examination or a performance test. In some cases a supplemental questionnaire will be required. Remember--there will not be a personal interview prior to establishing a register. If a performance test, written or oral examination is the evaluation method, you will be notified by mail of the date, time and place of the exam. You will receive notification indicating whether your name was referred for an interview, generally within two weeks of the closing date of the announcement. EMPLOYMENT EXPERIENCE Start with the most recent employment, give a complete record of all employment and reason for periods of unemployment (include military and volunteer service). Do not state “See Resume”. Note: If additional space is needed for your employment record, use a separate sheet of paper. Position title: Dates of employment (month & year) from to Number of hours worked per week: Employer (company) name and address: Phone: ( ) Supervisor’s Name and Title: Your duties: Ending Salary: Reason for leaving: May we contact your current employer? Yes No. If no, please explain: Position title: Dates of employment (month & year) from to Number of hours worked per week: Employer (company) name and address: Phone: ( ) Supervisor’s Name and Title: Your duties: Ending Salary: Reason for leaving: Position title: Dates of employment (month & year) from to Number of hours worked per week: Employer (company) name and address: Phone: ( ) Supervisor’s Name and Title: Your duties: Ending Salary: Reason for leaving: Position title: Dates of employment (month & year) from to Number of hours worked per week: Employer (company) name and address: Phone: ( ) Supervisor’s Name and Title: Your duties: Ending Salary: Reason for leaving: ---PAGE BREAK--- PERSONAL REFERENCES Give name and address of two persons who are well acquainted with your ability and character, but are not relatives or former employers. Name Complete Address Telephone Occupation Yrs. Known LICENSES/CERTIFICATIONS Please list any professional licenses or certifications that are relevant to the position for which you are applying, for example: CPR, Lifesaving, Water/Wastewater, P.O.S.T., EMT, Paramedic, I.C.C., Commercial Driver’s License, etc. SPECIAL SKILLS Summarize special job-related skills and qualifications acquired from employment or other experience. Include computer related experience, which software programs you have used, machinery or equipment expertise, other skills, etc: DRIVING INFORMATION Do you have a valid driver’s license? Yes No State Do you have a commercial driver’s licence (CDL)? Yes No State EDUCATION Have you graduated from High School or completed the GED equivalent? Yes No Name and location of High School School Name & Location (Include city and state) Academic Major Yrs Completed Did you graduate? Yes No Degrees Received Technical/Business College or University Graduate/Other I certify the information in this application is complete and accurate to the best of my knowledge. Any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I do hereby authorize any and all persons, companies, or agencies to release any and all background information, of a confidential or privileged nature, relevant to this application and any pertinent information they may have to the hiring authorities of Murray City Corporation. I release all such parties from all liability of every kind as the result of furnishing the same to Murray City Corporation. This information is to be used to assist the City in determining my qualifications and fitness for the position I am seeking. I hereby release Murray City and its officers, agents, and employees from any liability for the use of any and all of the foregoing information, in consideration for being reviewed for the aforesaid position. I understand that this employment application and any other City documents are not contracts of employment and that any oral or written statements to the contrary are hereby expressly disavowed. SIGNATURE DATE It is the policy of Murray City to develop, implement and maintain employment policies and practices that are based upon individual merit and are without regard to race, color, gender, age, religion, national origin, disability, veteran or citizenship status. In addition, it is the policy of this city to actively promote the realization of equal employment opportunity through voluntary compliance with the concepts and practices of affirmative action. ---PAGE BREAK--- I RECEIVED NOTICE OF WRITTEN EXAM Signature Date F O R H U M A N R E S O U R C E O F F I C E U S E O N L Y EXAMINATIONS Written Minimums ( ) Yes ( ) No Performance Education Oral Experience T & E Special Preference Pts Veterans Pref OVERALL Rev 3/98/2500; 6/99/2500; 5/01/2500; 8/02/3000; 10/03/3500; 12/06/2000; 10/2008/2000; 12/2010/1000 ---PAGE BREAK--- MURRAY CITY CORPORATION Affirmative Action Self-Identification Information It is the policy of Murray City Corporation to provide and promote equal opportunity employment, compensation and other terms and conditions of employment without discrimination because of race, color, gender, religion, national origin, age, or disability. The City provides reasonable accommodations to the known disabilities of applicants in compliance with the Americans with Disabilities Act. To help Murray City Corporation comply with Federal/State equal employment opportunity record-keeping, reporting and other legal requirements, please answer the questions below. Your answers to these questions are completely voluntary and failure to answer them will have no impact upon the decision to hire or not to hire you for the position for which you are applying. This pre-employment information will be kept in a CONFIDENTIAL FILE separate from the Employment Application. Position Applying for: Date: Last Name First Name Gender Age Male Female Under 16 16-17 18-39 40 or over Race/Ethnic Origin American Indian/Alaska Native Hispanic White Asian/Pacific Islander African American/Black Definitions of Ethnic Groups American Indian/Alaska Native - All persons having origins in any of original peoples of North America and who maintain cultural identification through tribal affiliation or community group. Hispanic - All persons of Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture or origin. Asian/Pacific Islander - All persons having origins in any of original peoples of the Far east, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa. White - All persons having origins in any of the original people of Europe, some North African countries, or the Middle East. African American/Black - All persons having origins in any of the Black racial groups of Africa. Do you claim Veterans Preference? Yes No. If you are claiming veteran or disabled veteran status, please provide a copy of your DD-214 showing dates of service with each application submitted. Referral Source - How did you learn about this position? Circle the one number from the list below: 1. Walk-in/Self 2. Newspaper Ad 3. Workforce Services 4. Job Interest Form 5. College/University Placement Office: Which? 6. Word of mouth/Friend/Relative/Murray City Employee: Which? 7. Agency or community group referral: Which? 8. Other: specify; 9. Murray City Web Site or other Internet Site Rev. 12/06 ---PAGE BREAK--- MURRAY CITY CORPORATION DRUG AND ALCOHOL TESTING, PRE-EMPLOYMENT PHYSICAL EXAMINATION AND CRIMINAL HISTORY BACKGROUND CHECK DISCLOSURE Murray City Corporation has implemented a drug screening program designed to prevent hiring individuals who use illegal drugs, or individuals whose misuse of legal drugs or alcohol may pose safety and health risks not only to the employee, but all those who they serve. Murray City Corporation is committed to providing a safe, healthy and efficient working place for all of its employees. The unlawful manufacture, distribution, dispensation, possession, or use of controlled substances is prohibited in the workplace. Testing positive for the use of illegal drugs or the misuse of legal drugs, or refusal to consent to the drug test, will be sufficient reason to deny employment. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying, except that no such information will be sought or obtained by the City until after a conditional offer of employment has been made. I acknowledge that Murray City requires an employment criminal history background check on all new employees/volunteers who are 18 years of age or older. My signature indicates I have read this document and understand its implications. Signature Date Rev 09/03