APPLICATION FOR EMPLOYMENT City of Henderson, N.C.

Transcription

1 APPLICATION FOR EMPLOYMENT City of Henderson, N.C. AN EQUAL OPPORTUNITY EMPLOYER Instructions: Please fill out all sections of this application to the best of your ability. Your application will be used as part of the examination process and therefore should represent your best effort. We appreciate your interest and thank you for making application for employment. PERSONAL 1. Position Applied For Date of Application 2. Name (Last) (First) (Middle) 4. Present Mailing Address (Street & No. or RFD) (City) (County) (State) (Zip Code) 5. Permanent Address (Street & No. or RFD) (City) (County) (State) (Zip Code) Telephone: Home If none, where can you be reached by phone? Business Resident's Name 6. Are you 18 or above? 7. Do you want to work Full-Time or Part-Time? Specify days and hours if part-time 8. Are you willing and able to work rotating shifts? 9. Have you worked for the City before? If yes, when and what position did you hold? When Position 10. List any relatives working for the City and your relationship to them 11. During the past 10 years, have you ever been convicted of a crime, excluding misdemeanors and traffic violations? ( ) No ( ) Yes (A conviction will not necessarily disqualify you from employment) Page 1

2 12. Do you have a valid driver's license? Chauffeur s license? 13. Clerical Skills: Typing Shorthand Other 14. Are there any other experiences, skills, or qualifications which you feel would be important to include? MILITARY HISTORY Have you ever served in the Armed Forces? ( ) Yes ( ) No Dates of duty: From To Rank at Discharge Are you presently in the Reserves or have any other obligation? EDUCATIONAL BACKGROUND Type of School Name & Address Dates attended Graduated Course or Major Grammar or Grade High School College Post Graduate Business or Trade Technical Other If you did not graduate from High School, did you obtain your GED equivalency? ( ) Yes ( ) No If "Yes", where did you obtain it? List the jobs that you have held beginning with your last or present employer. Include part-time jobs, military service, and/or periods of unemployment in the proper sequence. Failure to give complete information may result in rejection of your application. If more space is needed, use the continuation sheet on Page 4. Dates Name & Address of Employer Rate of Pay Supervisor's Name & Title Reason for Leaving Page 2

3 Dates Name & Address of Employer Rate of Pay Supervisor's Name & Title Reason for Leaving Dates Name & Address of Employer Rate of Pay Supervisor's Name & Title Reason for Leaving Dates Name & Address of Employer Rate of Pay Supervisor's Name & Title Reason for Leaving May we contact the employers listed above? If not, indicate below which ones you do not wish us to contact PERSONAL REFERENCES List three persons who are not related to you and who have definite knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed in Work History. Name & Occupation Address Phone Number We thank you for making application for employment with the City of Henderson, North Carolina. Page 3

4 AGREEMENT PLEASE READ CAREFULLY THE SECTION BELOW BEFORE SIGNING. YOUR SIGNATURE BELOW INDICATES YOU UNDERSTAND EACH OF THE STATEMENTS AND HAVE REQUESTED ASSISTANCE IN UNDERSTANDING ANYTHING WHICH MAY BE CONFUSING OR UNCLEAR. 1. I certify that the information contained in this Application for Employment is true to the best of my knowledge and belief and I understand and agree that any misrepresentation or false statement by me in connection with this Application for Employment will constitute justifiable cause for the City of Henderson not to employ me, or if employed based upon false information, to terminate my employment for cause. 2. I understand and agree that all information furnished in this Application for Employment may be verified by the City of Henderson. I hereby authorize all individuals and organizations named or referred to in this Application for Employment and any law enforcement organization to give the City of Henderson all information relative to such verification and hereby release such individuals, organizations and the City of Henderson from any and all liability for any claim or damage resulting therefrom. 3. I understand that as part of the processing procedures for consideration of my employment with the City of Henderson an investigation report may be made concerning my character, general reputation, and personal characteristics. Upon written request, additional disclosure concerning the complete nature and scope of the investigation will be provided. 4. I certify that I have complied with the requirements of the Federal Selective Service Registration Act to the extent they are applicable. 5. I understand that I will be required to furnish proof of eligibility for employment under the Immigration Reform and Control Act as a condition of employment by the City of Henderson. 6. I understand that, before being employment by the City of Henderson, I will submit to a Drug Screening Test, at the City's expense, and must satisfy the requirements of the City in this regard. Signature Date WE THANK YOU FOR MAKING APPLICATION FOR EMPLOYMENT WITH THE CITY OF HENDERSON, NORTH CAROLINA Page 4

5 PRE-EMPLOYMENT INFORMATION FORM Please answer the following questions to help us comply with Federal/State equal employment opportunity recordkeeping, reporting, and other legal requirements. This information will not be used in considering you for employment and the Pre-Employment Information Form will be kept in a confidential file separate from your Application for Employment. 1. Name:. Last First Middle 2. Birthdate: Month Day Year 3. Race/Ethnic Group: Caucasian Afro-American Other Hispanic American Indian 4. Sex: Male Female Position Applied For: Date:

6 Authorization to Obtain a Consumer Credit Report and Release of Information Pursuant to the federal Fair Credit Reporting Act, I hereby authorize City of Henderson and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic citations and registration; and any other public records. I authorize the City of Henderson to disclose the information and data, including my social security number, (filled in at the bottom of the Authorization) to others for the purpose herein so forth. I,, authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation or public agency may have. I understand that I must provide my date of birth to adequately complete said screening and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish City of Henderson or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original. I hereby release the City of Henderson and each responding entity and its respective agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release. You may contact me as indicated below. I understand that a copy of this authorization may be used (in lieu of the original) to request information and shall have the same validity as the original. I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer s right will be provided to me. Please Print Clearly 1. Name (Full) Maiden Last Name

7 Authorization Page 2 3. Print All Former Names Used, 4. Social Security Number Date of Birth Current Street Address 9. City, State Zip 10. Driver s License Number State Issued 12. Prior residence, past seven (7) years i. From To ii. From To By signing below, you are certifying that the above information is true and correct. Signature Date