Page 1

Received #

EMPLOYMENT APPLICATION PleaseNote FailuretoprovideALLapplicable information submitatypedorclearlyprintedform andoralateapplication mayresultinrejection

APPLYING FOR FirstName MiddleIntinal Last Name HomeAddress Mailing Address Home Phone SSN

MessagePhone

Other

OptionalUnlessHired DMV# State

OptionalUnlessRequiredforPosition

EMPLOYMENTEXPERIENCE Listcurrentandpastemployers inreversechronologicalorder mostrecentfirst usingaseparate blockfor eachjobheld evenwithsameorganization Alsolistanyjobrelatedvolunteer experience Attachadditional sheetsif necessary Resumesareacceptable butcannot substitute employmentsection Maywecontactyourpresentemployer NameofEmployer

Yes

No

MailingAddress SupervisorsName Title

Phone

Your ExactTitlePosition

StartEndDates

to

Describe YourDutiesforAbovePosition Include# ofEmployeesSupervised

EmploymentAverage TotalHours PerWeek ReasonforLeaving

Resigned

Full TimeHours

Discharged

Layoff

Part TimeHours

TemporaryHours

FinalSalaryRate $

PerHR WK MO

NameofEmployer MailingAddress SupervisorsName Title

Phone

Your ExactTitlePosition

StartEndDates

to

Describe YourDutiesforAbovePosition Include# ofEmployeesSupervised

EmploymentAverageTotalHours PerWeek ReasonforLeaving

Resigned

Full TimeHours

Discharged

Layoff

PartTimeHours

TemporaryHours

FinalSalaryRate $

PerHR WK MO

NameofEmployer MailingAddress SupervisorsName Title Your ExactTitlePosition

Phone StartEndDates

Describe YourDutiesforAbovePosition Include# ofEmployeesSupervised

to


EmploymentAverageTotalHours Per Week ReasonforLeaving

Resigned

Full TimeHours

Discharged

Layoff

PartTimeHours

TemporaryHours

FinalSalaryRate $

PerHR WK MO

NameofEmployer MailingAddress SupervisorsName Title

Phone

Your ExactTitlePosition

StartEndDates

to

Describe YourDutiesforAbovePosition Include# ofEmployeesSupervised

EmploymentAverageTotalHours PerWeek ReasonforLeaving

Resigned

Full TimeHours

Discharged

Layoff

Part TimeHours

TemporaryHours

FinalSalaryRate $

PerHR WK MO

ANEQUALOPPORTUNITY EMPLOYER EDUCATIONTRAINING Name LocationofHighSchool Study Emphasis Didyougraduate

Yes

StartEndDate s

to

StartEndDate s

to

No

Name LocationofCollegeUniversity Study Emphasis Did yougraduate receivea degreeorcertificate

Yes

No

Whattype

Name LocationofOtherSchool Study Emphasis

StartEndDate s

Didyougraduate receivedegree orcertificate

Yes

No

to

Whattype

Listanycourses seminars orrelatedtraining including title lengthofcourse andorprofessional orvocationalcertificates receivedwhichwouldincreaseyoureffectivenessinthisposition

Listanyadditional informationyouwishtoincluderegardingyourqualificationsorinterest pertinenttothisposition Exclude legally protectedinformationofwhichitscharacterwillindicatethe race religiouscreed nationalorigin ancestry sex physicalcondition orstatusofthe applicant

ClericalApplicantsOnly Typing

WPM Shorthand

WPM

SubjecttoVerification

REFERENCES Givename homeorbusinessaddress andtelephonenumberofthreepersons NOTrelatedtoyou whohave knowledgeofyourcharacter workexperienceandability ReferencesName Title

Phone

MailingAddress ReferencesName Title

Phone


MailingAddress ReferencesName Title

Phone

MailingAddress ADDITIONAL QUESTIONS Pleaseanswerthefollowingquestions andattachadditional sheetsasnecessary HaveyouworkedfortheCityofHighland AreyourelatedtoanyCityemployee

Yes Yes

No Ifyes reasonforleaving No Ifyes givename relationship

Criminalrecord doesnotconstituteanautomaticbartoemployment Please fullyexplainallYesanswers Haveyou everbeencitedandconvictedforanyvehiclecode violationotherthanaparking violation Haveyou everbeenconvictedofafelony oramisdemeanor Haveyou everbeendischargedorforcedtoresigndue tomisconductorunsatisfactoryservice Ifrequiredoftheposition areyouavailabletoworknights holidays andorweekends WouldyouconsideraPart timeorTemporaryworkschedule Ifselectedand youareunder18yearsofage canyouprovidetherequiredproofofyoureligibilitytowork Ifselected onwhatdatewouldyoubeavailabletowork

Yes Yes Yes

No No No

Yes Yes Yes

No No No

Iherebycertifythatallstatementsonthisapplicationaretrueandcompleteandthat anymisstatementoromissionof materialfactswillsubjectmetodisqualificationordismissal Iherebyauthorizeanyformeremployersandreferences tofurnishtheCityofHighlandtheirrecordsof myservices reasonsforleaving theiremploy andallotherjobrelated informationthatmayconcernme whetherornotarecord Iherebyreleaseany ofmyformeremployers theiragents oranyotherreferencesfromallliabilityforanydamages whatsoever infurnishingsaidinformation Iunderstand that theuse ofthisform doesnotindicatethereareanypositionsopenanddoesnot in anywayobligatetheCityofHighland Further Iunderstand thatifselectedasthefinalcandidate Iwillberequiredto successfullycompleteapreemployment physicalwhich includesdrug andalcoholtestingbyaCitydesignatedphysician provideproofofidentity suchassocial securitynumberanddriver slicensenumber anddocumentationverifyingauthorizationtowork intheUnitedStates Signature

Date

OFFICEUSEONLY Received Contacted

at at

ampmby ampmby

Denied

Accepted

1stInterview

2ndInterview


APPLICANT BACKGROUNDINFORMATION PleaseNote Inclusionorexclusion ofanydataonthisformwill NOTaffectany employmentdecision Yourcooperation isvoluntary APPLYING FOR Inordertocomply withEqualOpportunityregulationsandAffirmativeActionresponsibilities wheretheyapply youare requestedtocompleteand returnthis formwithyouremployment application Thisformwillbedetached fromyourapplication andwill bekeptseparateandconfidential Employeesaretreatedwithoutregardtorace religion sex nationalorigin age maritalorveteranstatus medicalconditionordisability oranyother legallyprotectedstatusduringemployment NAME SEX

Male

AGEGROUP

Female Under21

2129

3039

4049

50 59

60orOver

ETHNICORIGIN White

Allpersons havingoriginsinanyoftheoriginalpeoplesofEurope NorthAfrica MiddleEast ortheIndianSubcontinent NotofHispanic Origin

Black

Allpersonshavingoriginsinanyoftheblackracialgroups NotofHispanicOrigin

Hispanic

Allpersons ofMexican PuertoRican Cuban CentralorSouthAmericanorother Spanishculture ororigin regardlessofrace

AsianorPacificIslander

Allpersons having originsinanyoftheoriginalpeoplesoftheFarEast Southeast Asia orthePacificIslands

AmericanIndianorAlaskan Native

Allpersonshavingoriginsinanyofthe originalpeoplesofNorthAmerica

ADVERTISING SOURCE Pleaselistwhere howyoubecame awareofthisjobopening Newspaper Journal Radio Television Bulletin Other Thankyouforyourparticipation

test 5  

test 5,test6