Town of Sellersburg EMPLOYMENT APPLICATION. Applicant Name

Transcription

1 wn of ellersburg Y II pplicant ame

2 he wn of ellersburg considers applicants for all positions without regards to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non job-related medical condition or disability, or any other legally protected status. II F Y W F BUG QU UIY Y UII WK 103 outh ew lbany treet ellersburg, I osition applied for pplication ate ate vailable inimum acceptable salary egular Full ime egular art ime emporary art ime emporary Full ime : opies of diploma(s) or college transcript(s) must be included with this application if applicable for position applying for. ame (ast, first, middle) (roof of identity will be required upon employment) ocial ecurity umber U I J B re you authorized to work in the U.. on an unrestricted basis? (roof of citizenship or immigration status will be required upon employment) Yes o ddress (treet & number or.. Box, ity, tate, Zip code) re you at least 18 years old? Yes o hone (rea code and number) lternate hone (rea code and number) o you have any relatives working for the wn of ellersburg? Yes o If "yes," list names, relationships, and department employed. Have you ever been convicted of a Felony? Yes o If "yes," describe location, date and offense. (onviction will not necessarily disqualify an applicant from employment.) If the position for which you are applying requires operation of a motor vehicle, list any traffic violations occurring during the past five years: Yes o If "yes" epartment: When? Graduated Yes o Have you ever been employed by the wn of ellersburg? ype of chool ame and ocation of chool umber of em. Hrs. ompleted HIGH H G UIVIY HI VI icenses or certificates (river's icense...) Y F WK XI y lerical ccounting ata rocessing onstruction ype of egree or iploma ther (list) Indicate below which machine and other job skills you have: computer word processing shorthand, speed wpm key station terminal () adding machine dictaphone, speed wpm G... ajor K I typewriter, speed wpm calculator ther onstruction ols aintainers/bulldozers Backhoes/Front loaders ractors/owers ump trucks ther ist Foreign anguages peak ead Write tate any additional information you feel might be helpful to us in considering your application. How were you referred to the wn of ellersburg? If referred by an employee of the wn, give name and department. re you currently employed? Yes o re you available to work shift work? Yes o re you available to work temporary work? Yes o re you currently on "layoff status and subject to recall? Yes o

3 WK HIY (cont'd) II F Y omplete the following, do not say "see resume." tart with your most recent employment and work back. Be sure to include employer's mailing address. ist employment for previous 10 years. Include military service and volunteer activities, if any. Y W YU Y F F? Yes o 1 (Firm,, etc.) ity, tate, Zip code) ates of mployment (month, year) alary or arnings tarting $ er nding $ er Y quipment used: 2 (Firm,, etc.) ates of mployment (month, year) quipment used: 3 (Firm,, etc.) ates of mployment (month, year) quipment used: 4 (Firm,, etc.) ates of mployment (month, year) quipment used: 5 (Firm,, etc.) ates of mployment (month, year) quipment used: umber of mployees umber of mployees umber of mployees umber of mployees umber of mployees alary or arnings tarting $ er nding $ er alary or arnings tarting $ er nding $ er alary or arnings tarting $ er nding $ er alary or arnings tarting $ er nding $ er

4 WK HIY (cont'd) II F Y omplete the following, do not say "see resume." tart with your most recent employment and work back. Be sure to include employer's mailing address. ist employment for previous 10 years. Include military service and volunteer activities, if any. 6 (Firm,, etc.) ates of mployment (month, year) alary or arnings tarting $ er nding $ er Y quipment used: 7 (Firm,, etc.) ates of mployment (month, year) quipment used: 8 (Firm,, etc.) ates of mployment (month, year) umber of mployees Youupervised umber of mployees umber of mployees alary or arnings tarting $ er nding $ er alary or arnings tarting $ er nding $ er F quipment used: If you need additional space, please continue on a separate sheet of paper. ist below three persons to whom we may refer for information about your character or qualifications. IU Y, IV, UVI. IU H H F. ame ity, tate & Zip ode ccupation

5 II F Y H FWIG FUY II YU UIG BY IGIG YU I H II. 1. I certify that answers give herein are true and complete to the best of my knowledge. 2. I agree that any written or oral misrepresentations or omissions made in making this application will be grounds for immediate dismissal. 3. I understand that I may be required to provide the wn of ellersburg with a "criminal clearance letter" if I apply for a job working on private property or handling money. 4. I understand that the wn of ellersburg is entitled to obtain criminal history record information maintained by the tate of Indinana that relates to any applicant for employment 5. I understand that I will be required to authorize release of financial information, including credit history information if I apply for a job in law enforcement or a job handling money. 6. I hereby authorize all former employers and their employees as well as other references listed on this application to answer any questions, and to furnish any accurate information from their records concerning me, and I hereby release such companies and persons from any liability for such actions. 7. his application for employment shall be considered active for a period of time not to exceed 45 days. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that effect is executed by the employer and employee in writing. I understand, also, that I am required to abide by all rules and regulations of the employer as a condition of employment. 8. I understand that upon an offer of employment I will be required to pass a physical exam and drug screening as a condition of employment. II U B IG pplicant ignature ate For personnel department only rrange Interview Yes o (if no, give explanation) mployed Yes o ate of mployment Job itle Hourly ate/alary epartment dditional otes By ame & itle ate IB I F I I I Y G F H II HU H UBI WK I (812) XI 7. ev (01/09)