Full Text
Prepared by Town of Pahrump Human Resources Page 1 of 5 October 2018 Town of Pahrump – Human Resources 2100 E Walt Williams Suite 110 Pahrump, NV 89048 (775)751-6301 Application for Employment An Equal Opportunity Employer Town of Pahrump is an Equal Opportunity Employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at US Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W. Washington, DC 20250-9410, by fax (202) 690- 7442 or email at [EMAIL REDACTED] Please Print Clearly First Name: Middle Initial: Last Name: Today’s Date: Mailing & Physical Address if different: E-mail address: City, State, Zip: Home Telephone: ( ) Position applied for: Department: Cell Phone: ( ) How did you hear about this position? Advertisement Walk-In Referral (by whom?) Other (Explain)? If offered employment, when can you begin? What type of employment will accept? Full Time Part Time Temporary Will you work weekends & holidays if necessary? Yes No Have you been given a job description or had the requirements of the job explained to you Yes No Do you understand the job requirements? Yes No Can you perform the requirements of this job with or without reasonable accommodation? Yes No To qualify for employment, you must be at least 18 years of age, unless otherwise specified in the advertisement. If offered employment can you furnish proof of age? Yes No Can you provide verification of your legal right to work in the United States? Yes No List any other names, if any, you have used: Did you graduate from High School or receive a GED certificate? Yes No Education: Name City & State Degree Earned Major Course of Study High School College Graduate, Trade or Business School ---PAGE BREAK--- Prepared by Town of Pahrump Human Resources Page 2 of 5 October 2018 LICENSES (Optional, unless required for the position for which you are now applying.) List current licenses, certifications, or registrations required for the position for which you are applying. Indicate types, state license numbers, and expiration dates. (Answer only if position requires) Do you possess a valid driver’s license? Yes No If so, expiration date? Class Restrictions (if any) For positions that require typing: I certify I can type at a speed of WPM. In addition to English, list other languages you are fluent in, verbal and written: List any special skill you possess and/or equipment or office machines you can operate. OTHER INFORMATION Have you ever been disciplined in your employment related to workplace violence? Yes No If yes, please explain: Do you presently use illegal drugs? Yes No Have you even been employed by the Town of Pahrump? Yes No Department: Title: Dates of Employment: for Separation: Are you related to anyone currently employed by the Town of Pahrump? Yes No If yes, person’s name Department: ---PAGE BREAK--- Prepared by Town of Pahrump Human Resources Page 3 of 5 October 2018 FOR POSITIONS, OTHER THAN THOSE IDENTIFIED ABOVE: • The criminal history of an applicant will only be considered after the final interview which is conducted in person or an offer of employment has been made, whichever occurs first. • THE TOWN OF PAHRUMP may, before selecting an applicant as a finalist or extending a conditional offer, notify the applicant of any provisions of law that disqualify a person with a particular criminal history from employment in a particular position. • A record of conviction will not necessarily bar the applicant from employment. Factors to be considered when looking at records of criminal history include: o Length of time passed since the offense; o Age of applicant at the time of the offense; o Severity and nature of the offense; o Relationship of the offense to the position applying for; and o Evidence of rehabilitation of the applicant. • The following will not be considered: o Arrests which did not result in a conviction; o Record of convictions that were dismissed, expunged, or sealed; and o Infractions or misdemeanors for which a sentence of imprisonment in a county jail was not imposed. THIS SECTION IS TO BE COMPLETED ONLY IF YOU ARE APPLYING FOR A POSITION: • AS A PEACE OFFICER OR FIREFIGHTER. • WHICH HAS ACCESS TO THE NEVADA CRIMINAL JUSTICE INFORMATION SYSTEM OR THE NATIONAL CRIME INFORMATION CENTER. • WHICH A STATE OR FEDERAL LAW REQUIRE CRIMINAL HISTORY INFORMATION. Have you ever been convicted of, pled guilty or nolo contendere to, or been granted deferred adjudication for a felony, misdemeanor (excluding juvenile adjudication), or any lesser crime other than a minor traffic infraction?..... Yes No Do you have any pending court charges that have not been Yes No If you have answered yes to either question, list all such offenses and provide date, name of court, and disposition (if any). You may omit minor traffic violations for which you paid a fine of $50 or less. Omission of information may be considered cause for disqualification from the employment pre-screening process or result in termination of employment. ---PAGE BREAK--- Prepared by Town of Pahrump Human Resources Page 4 of 5 October 2018 APPLICANT’S NAME: EMPLOYMENT HISTORY Provide information regarding all paid, military and volunteer work which may be related to the position for which you are applying. Describe your most recent position first; then list other positions in order held, starting with the most recent. Use a separate block for each position held, even if with the same employer. Use additional sheets if necessary. Do NOT use references such as “See Resume” in place of completing this section. May we contact all organizations listed? Yes No *Attach a list of any exceptions with an explanation* Organization: Dates Description of duties: From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Organization: Dates Description of duties: From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Organization: Dates Description of duties: From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Organization: Dates Description of duties: ---PAGE BREAK--- Prepared by Town of Pahrump Human Resources Page 5 of 5 October 2018 From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Organization: Dates Description of duties: From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Organization: Dates Description of duties: From To Complete Address (Street/PO, State, City, Zip) Telephone Number(s) Hourly Rate/Salary if applicable Starting Final Job Title Supervisor’s Name & # Reason for leaving: Please state below any other information that would be helpful in determining your qualifications for the position. You may include significant accomplishments, previous career highlights, or any other relevant information that is not requested in this employment ---PAGE BREAK--- Prepared by Town of Pahrump Human Resources Page 6 of 5 October 2018 ACKNOWLEDGMENTS Please READ ALL of the following statements and INITIAL EACH of the lines to indicate you have read and understand each of the statements. If you have questions, contact Ryanne Gott at (775) 751-6301 or [EMAIL REDACTED]. All offers of employment and all information regarding compensation and other terms and conditions of employment will be made in writing. Verbal statements may not be relied upon. This application is the property of the Town of Pahrump and will become part of my personnel file if I am hired. I authorize the Town of Pahrump to contact any organization or individual that I have listed on my application and/or résumé or mentioned in job interviews, and to obtain from them any relevant information regarding my previous employment, military service, criminal history, characteristics or traits necessary for job performance, or other relevant qualifications for employment and/or continued employment with the Town of Pahrump. In addition, I authorize the Town of Pahrump to conduct a background search which includes criminal history and military history. In addition, if the position for which I am applying requires driving a vehicle, I authorize the Town of Pahrump to conduct a Department of Motor Vehicles (DMV) search. If the position for which I am applying involves contact with minors or with any persons having diminished capacity to care for themselves, a search of government sex offender registries may be conducted. I further authorize the Town of Pahrump to contact any institution and/or licensing authority to verify my possession of education, licenses or certificates which may qualify me for employment with the Town of Pahrump. In exchange for the Town of Pahrump’s consideration of my employment application, and/or any continued employment with the Town of Pahrump, I authorize anyone possessing this information to furnish it to the Town of Pahrump upon request, and I release the organization and all individuals providing the information or acquiring the information, including the Town of Pahrump, from all claims, liability, and damages whatsoever claimed to be related to furnishing, obtaining, or using said information. This release applies to, but is not limited to, claims for defamation, libel, slander, infliction of emotional distress, and interference with current or prospective economic relations. I further understand this consent will apply during the entire course of my employment with the Town of Pahrump should I obtain such employment. I understand and agree this consent shall remain in effect indefinitely. I hereby certify that all statements made in this application are true. I understand that any false statement of material facts herein may cause forfeiture on my part of all rights to any employment with the Town of Pahrump. I understand that any misrepresentation, falsification, or material omission of information may result in my failure to receive an offer, or if I have been hired, in my dismissal from employment regardless of length of employment. I understand that neither this document nor any offer of employment from the Town of Pahrump constitutes an employment contract unless a specific contract document to that effect is executed. I agree to undergo any job-related physical examination and drug screening upon conditional offer of employment. I further understand and agree that this paragraph applies to any information supplied by me at a later date as part of this application. Additionally, my signature below certifies that the information provided is true and correct to the best of my knowledge. Signature of Applicant: Date: