City of Palmer Human Resources Specialist 231 W. Evergreen Avenue Palmer, AK 99645 Phone: 907-745-3271 Fax: 907-745-0930 Employment Application Application Date: Last Name: First: Middle: Other Names Used for Employment: Mailing City: State: Zip Code: Phone Numbers: Home: Cell: Business/Message: Email address: Are you eligible for employment in the United States : Yes No If necessary for the job, are you over: (please check the appropriate box) 14 15 16 17 18 19 20 21 Position(s) Desired: (please check the applicable box(es)) Full-time: Part-time: Temporary: On-Call: Pay Rate Desired: $ Available Start Date: Position Desired: Are you willing to perform shift work? Yes No Are you willing to work weekends? Yes No Are you willing to work holidays? Yes No Do you have a valid driver s license? Yes No
If yes, list the state, number, and expiration date: Please list any special skills or training that make you qualified for this position: Please list your professional licenses, certificates or registrations: Have you been employed by the City of Palmer in the past? Yes No Please list the name(s) of your relative(s) now employed by the City of Palmer: Are you able to perform the necessary functions of this job with or without reasonable accommodations? Yes No Education High School Name of School: Location: Course of Study: Number of Years Completed: Did you graduate? Degree or Diploma:
College (Undergraduate) Name of School: Location: Course of Study: Number of Years Completed: Did you graduate? Degree or Diploma: College (Graduate) Name of School: Location: Course of Study: Number of Years Completed: Did you graduate? Degree or Diploma: Other (Specify) Name of School: Location: Course of Study: Number of Years Completed: Did you graduate? Degree or Diploma:
Employee Work History Start with present or most recent employer. Please give accurate, complete full-time and part-time employment. Include any job-related military service and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status. Additional pages may be used if needed. Do not write See Resume. Company Name: Job Title: Telephone Number: Supervisor s Name & Telephone Number: Supervisor s Email Briefly describe your duties: Employment Dates: Rate of Pay: From: To: Start: Final: Reason for Leaving:
Company Name: Job Title: Telephone Number: Supervisor s Name & Telephone Number: Supervisor s Email Briefly describe your duties: Employment Dates: Rate of Pay: From: To: Start: Final: Reason for Leaving:
Company Name: Job Title: Telephone Number: Supervisor s Name & Telephone Number: Supervisor s Email Briefly describe your duties: Employment Dates: Rate of Pay: From: To: Start: Final: Reason for Leaving: Unless indicated, we may contact the preceding list of employers. Please list those you do not wish us to contact. Do Not Contact: Reason:
Please list three references: Name: Phone Number: Email: Name: Phone Number: Email: Name: Phone Number: Email: *Have you ever been convicted of a felony? Yes No If yes, please explain: *Have you ever been convicted of a misdemeanor other than minor traffic violations? Yes No If yes, please explain: *Have you ever had your driver s license suspended or revoked as a result of a moving violation(s)? Yes No If yes, please explain: *Information supplied regarding conviction record will not necessarily bar applicant from consideration for employment. Nature of, reason for, and time elapsed since conviction will be reviewed in light of the duties of the job sought. If typing test is required for position, you must submit a certified typing test from the job service, and should be attached to the application.
The information provided in this employment application is true, correct, and complete. If employed, any misstatement or omission of fact on this application may result in dismissal. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This authorization includes permission to check employment references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the U.S., have a physical examination and/or drug test, or to sign a conflict of interest agreement and abide by its terms. I understand that acceptance of an offer of employment does not create a contractual obligation or permanent employment upon the City of Palmer. Employment may be terminated at any time at the option of the employee or City of Palmer. I understand and agree to the information shown above. Applicant Signature Date