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City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 1 of 6 APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer / Provider To be considered an applicant, you must complete this form. A resumé may also be attached. Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for your signature. This application is to fill the current open position only. Personal Information: Name: Last First Middle Address: Street City State Zip Telephone: ( ) ( ) / / Home Cell Today’s Date Email Address: Webpage Address(es): Position Applying For: Job Title: Are you applying for: ☐F/T ☐P/T ☐Temp/Seasonal What shifts will you work? ☐Days ☐Nights May We Contact Present Employer? ☐ Yes ☐ No Available Start Date: Are you legally eligible to work in the United States? ☐Yes ☐No (Federal Law requires proof of identity and employment authorization for all new employees.) Can you travel if the job requires it? ☐ Yes ☐ No Do you have a valid driver’s license? ☐ Yes ☐ No State: Education/Training: School Name Location tes Attended From / To: oma, Degree & Major Graduated? High School College Other (Business, Vocational, Military) ---PAGE BREAK--- City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 2 of 6 Employment History: (Please Start With the Most Recent, Excluding Part-Time Positions Held While Obtaining Higher Education—Use Additional Paper as Necessary.): Employer: Address: Street City State Zip Telephone:( ) Supervisor Name: Dates From: To: Final Rate of Pay: Position Held: Primary Duties: Reason for Leaving: Next Employer: Employer: Address: Street City State Zip Telephone:( ) Supervisor Name: Dates From: To: Final Rate of Pay: Position Held: Primary Duties: Reason for Leaving: Next Employer: Employer: Address: Street City State Zip Telephone:( ) Supervisor Name: Dates From: To: Final Rate of Pay: Primary Duties: Reason for Leaving: Position Held: ---PAGE BREAK--- City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 3 of 6 Technology Skills: (List All Skills & Software Applications You Have Experience Using): Word Processing: Spreadsheet: Other Software: Database: Microsoft Office? Yes ☐ No ☐ PowerPoint? Yes ☐ No ☐ Scanner? Yes ☐ No ☐ Copier? Yes ☐ No ☐ Digital Phone Systems? Yes ☐ No ☐ Explain Internet Skills, Including Email Usage: Professional Licenses or Certificates Held: Military: Are you a veteran or family member who qualifies for and are claiming preference pursuant to Idaho Code Yes ☐ No ☐ § 65-503 or its successor? (If Yes, fill out Page 5 of Application & attach proper documentation) Have you previously claimed such preference? Yes ☐ No ☐ Personal Reference: (Please list the names of three persons not related to you by blood or marriage.) Name: Last First Middle Address: Street City State Zip Telephone: ( ) ( ) Home Other Connection To You (i.e. friend, co-worker): Occupation: Personal Reference: Name: Last First Middle Address: Street City State Zip Telephone: ( ) ( ) Home Other Connection To You (i.e. friend, co-worker): Occupation: Personal Reference: Name: Last First Middle Address: Street City State Zip Telephone: ( ) ( ) Home Other Connection To You (i.e. friend, co-worker): Occupation: ---PAGE BREAK--- City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 4 of 6 Have you ever been charged with a crime (other than a minor traffic infraction)? Yes ☐ No ☐ If yes, when & Please Explain: Are you related by blood or marriage to any person now employed by Employer? Yes ☐ No ☐ If yes, give name and relationship to you: CERTIFICATION I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my employment may be terminated. I understand and agree that, if hired, my employment is for no definite period and either Employer or I may terminate our relationship at any time, and that this employment application does not constitute an employment contract. Signature of Printed Name:_ IT IS THE POLICY of The City of Star to provide equal opportunity in all terms, conditions and privileges of employment for all qualified job applicants and employees without regard to race, color, national origin, gender or age (unless a bona fide job requirement) or the presence of any disability. Reasonable accommodations will be made for disabled persons. ---PAGE BREAK--- City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 5 of 6 VETERAN’S PREFERENCE Part 1. Preference Eligible Veterans: □ I served on active duty at any time from 12-7-41 and ending 7-1-55. □ I served on active duty for 180 consecutive days, any part of which occurred after 1-31-55 and before 10-15-76. □ I served on active duty at any time from 8-2-90 and ending 1-2-92. □ I served on active duty for a period of more than 180 consecutive days, any part of which occurred during the period beginning on 9-11-01 and ending when prescribed by Presidential proclamation or by law as the last date of Operation Iraqi Freedom. □ I have been awarded an Armed Forces Expeditionary Medal (AFEM). All AFEM recipients, whether listed here or not, qualify for veteran’s preference and must be shown on your DD-214 form. Examples of some of the most common campaign medals are: Vietnam (Service Medal), El Salvador, Lebanon, Granada, Panama, Bosnia, Kosovo, Afghanistan, Southwest Asia (Persian Gulf), Somalia, and Haiti. (Award of the National Defense Service medal does not qualify.) For a listing of Wars, Campaigns, and Expeditions of the Armed Forces which qualify for veteran’s preference, go to www.opm.gov/veterans/html/vgmedal2.htm. □ I have a service-connected disability of 10% or more. □ I am the spouse of an eligible disabled veteran, who has a service-connected disability. □ I am the widow or widower of an eligible veteran and have remained unmarried. □ I do not meet any of the selections above, but I served on active duty in the armed forces of the United States for a period of more than one-hundred eighty (180) days and was honorably discharged. Part 2. Documentation & Signature. By my signature, I certify that all statements on this form are true and complete to the best of my knowledge. I understand that should an investigation disclose inaccurate or misleading answers, my application may be rejected and my name removed from consideration for employment with ICRMP. □ I have never received veteran’s preference by any State of Idaho agency. (If you have received an initial appointment claiming veteran’s preference, you are not eligible for preference.) □ I have attached a copy of my DD-214. Veteran’s preference will not be considered without this document. Signature of Printed Name:_ ---PAGE BREAK--- City of Star P.O. Box 130 Star, ID 83669 [PHONE REDACTED] [EMAIL REDACTED] Application for Employment Form #222 05-2022 Page 6 of 6 WE CONTACT YOUR PRESENT EMPLOYER? Yes ☐ No ☐ AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I, _ , an applicant for employment with do hereby authorize a review of and full disclosure of all records or information concerning myself to any duly authorize agent of City of Star, whether the said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of all records and information of educational institutions; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, either criminal or civil, in which I have, or have had any interest or involvement. I understand that any information obtained during any personal history background investigation which is developed directly or indirectly, in whole or in part, upon this authorization will be considered in determining my suitability for employment by the _ . I hereby agree that any person(s) or entities who may furnish such information concerning me shall not be held liable for providing this information; and I do hereby release said person(s) and entities from any and all liability which may be incurred as a result of furnishing such information. I further authorize that a photocopy of this signed release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. Signature of Printed Name:_ Printed Name, including all names you have previously used or been known by: _ _ _ _ _ _ Phone:_ _ _