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1 City of Salem Employment Application Human Resources Department 98 Washington Street, 3rd Floor, Salem, Massachusetts 01970 Phone: [PHONE REDACTED] www.salem.com An Equal Opportunity/Affirmative Action Employer The City of Salem is an equal opportunity employer and does not discriminate against any applicant because of race, color, religion, sex, marital status, national origin, age, disability, sexual orientation or any other class protected by federal, state or local law. Any person who needs assistance in fully participating in the application process should contact the City of Salem Human Resources Department. A resume, cover letter, and fully completed application is required for each position applied for. Also, “see resume” is not acceptable in any field. I. Contact Information Name Date Address # and Street City and State Zip Code Telephone II. Position Applying For (Please specify position title) How did you hear about the position? Have you ever been employed by the City of Salem? When? What department? III. Education School Name, Address, City, State Years Attended Degree High School College Graduate School Trade, Business, Night Courses Military Service, Other Training IV. Licenses (Please list all licenses related to the position you seek) Do you have a valid driver’s license (Class D Auto)? Yes No If yes, enter expiration Do you have a valid CDL license (Class A or Yes No If yes, enter expiration date Do you have a valid Hydraulic license? Yes No If yes, enter expiration What other valid licenses or certifications do you possess (job related)? V. Office Skills (If applicable) Check the column that you feel best describes your knowledge: √ Beginner √ Intermediate Level √ Advanced Level Microsoft Word Microsoft Excel Microsoft Access Microsoft Power Point Bookkeeping Knowledge Transcription Ability Shorthand/Speedwriting Ability VI. Special Skills Please list any other skills or abilities you feel are relevant: ---PAGE BREAK--- 2 VII. Employment History (Please do not write “see” resume) Please account for the last 4 positions you have held. Start with your present or last employer. You may include military service and any verifiable work performed as an intern or volunteer. We may may not contact your present employer. Employer Address Telephone Title Supervisor Dates Worked Reason for Leaving Description of Primary duties: Employer Address Telephone Title Supervisor Dates Worked Reason for Leaving Description of Primary duties: Employer Address Telephone Title Supervisor Dates Worked Reason for Leaving Description of Primary Employer Address Telephone Title Supervisor Dates Worked Reason for Leaving Description of Primary ---PAGE BREAK--- 3 VIII. Business References (a minimum of 3 references required, please do not write “see resume”) Name Address Phone Relationship Name Address Phone Relationship Name Address Phone Relationship X. Employment of Minors The City of Salem is subject to certain child labor provisions regarding the employment of persons under the age of 18. Further, an Employment Permit or Educational Certificate may be required, depending on your age. Are you under age 18? If yes, please indicate your age: Can you furnish a work permit? XI. Pre-Employment Physical Examination and drug testing: All offers of employment are conditional upon a physical examination, where required. Satisfactory fitness to perform the essential duties of the position is a condition of employment. All offers of employment are conditional upon the satisfactory completion of a pre-employment drug test, where required. Satisfactory completion of a required drug or alcohol test is a condition of employment in the City of Salem. XIV. Signature CAREFULLY READ ALL PARTS OF THIS APPLICATION FORM BEFORE SIGNING. A. I understand that acceptance of this application by the City of Salem does not imply that I will be employed. B. The information I have provided is true and complete. I understand misrepresentation or omission of any fact in my application, resume, or in any other materials or as provided during interviews, can be justification for refusal of employment or can be justification for termination from employment, if employed. C. I understand any offer of employment I receive from the City of Salem is contingent upon my successful completion of the pre-employment screening process including but not limited to the City of Salem receiving satisfactory references, a satisfactory criminal history and Criminal Offense Record Inquiry if required, satisfactory verification of driver’s license or certifications where required and satisfactory completion of any required post-offer pre-employment drug test or physical examination. D. In processing my application for employment, the City of Salem may verify information provided by me concerning, among other things, my prior employment, military record, education, character, general reputation and personal characteristics. E. I authorize the City to take whatever steps deemed necessary to obtain information regarding my qualifications for employment including contacting my present and former employers, by contacting individuals listed as business, educational or personal references, and by contacting other individuals to provide or further clarify information about me. F. I hereby release the City, my present and former employers and all individuals contacted for factual information about me from any and all liability for damages arising from furnishing the requested information. G. If offered a position with the City of Salem, I understand that as a condition of employment, I may be required to furnish additional or updated medical information, that I may be required to undergo a physical examination, that I may be subject to drug and/or alcohol testing, that the City may request a Criminal Offense Record Inquiry (CORI check) on me, investigate my driving record or verify my license(s) or certification(s) as required for employment at any time during my employment. I hereby authorize the City to conduct a CORI check on me as a condition of applying for a position with the City, where applicable, and agree to sign a CORI Request Form reflecting my authorization of the CORI check. I further release the City and its agents from any and all potential claims associated with the City’s performing a CORI check on me in connection with my application for a position with the City. As a condition of employment an employee may be required to provide additional or updated information especially if this employee has been on workers comp and may require both drug testing and an employment physical in order to allow us to have the necessary information for making a proper decision or reasonable accommodations, if necessary. H. I understand that the City of Salem is an at-will employer. If employed, I understand my employment may be terminated with or without cause at any time unless there is an applicable bargaining unit contract provision. My signature certifies I have read and agree with statements above and all statements in this application for employment. Applicant’s printed name and date Applicant’s signature