CITY OF POMEROY
APPLICATION FOR EMPLOYMENT
Thank you for your interest in employment with the city of Pomeroy. We consider all job applicants solely on the basis of job-related qualifications. We are an equal opportunity employer and do not discriminate in any aspect of employment on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, age, ancestry, veteran status, physical or mental disability or any other legally protected status in accordance with the requirements of local, state, or federal law. Please inform us if you require any reasonable accommodation to complete this application or to participate in any employment test or interview. Please complete this application fully and accurately. If you are unable to recall specifically any item of information requested, please so indicate. All the information you provide is subject to verification. A complete resume may be requested.
Today’s Date: __________________________ Applicant must re-apply if not hired within 60 days.
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LAST NAME FIRST NAME MIDDLE
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ADDRESS
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CITY STATE ZIP CODE
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HOME PHONE ALTERNATE PHONE
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TYPE OF WORK OR POSITION DESIRED______________________________ SALARY DESIRED_______________
DATE AVAILABLE TO BEGIN WORK ___________ DAYS AVAILABLE___________ HOURS AVAILABLE_________
Are you legally authorized to work in the U.S.? YES/NO ______
(You will be required to submit verification of your legal right to work in the U.S. upon employment).l
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Have you ever worked for the City of Pomeroy (including as an independent contractor)? If so, please tell us when and in what capacity: ___________________________________________________________________
How did you learn of job opportunities with the City of Pomeroy?_____________________________________
Have you been convicted of a felony in the past seven years? If so, please explain._______________________
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A conviction will not automatically bar employment, but will be considered as it relates to fitness and ability to perform the job in question. Failure to honestly answer this question will result in discontinued consideration of application or termination of employment.
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EDUCATIONAL BACKGROUND
Highest level of education completed:___________________________________________________________
List any professional licenses, certificates, related training or education including any military training/experience:_________________________________________________________________________
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EMPLOYMENT HISTORY
Complete this employment history, even if you also submit a resume. Start with your most recent employment and list all jobs you have held in the past 10 years. Begin with most recent employer. Account for all time, whether employed or not.
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Employer ________________________________ Employed from: Mo./Yr to Mo./Yr.____________________
Address___________________________________________________________________________________
City________________________________ State_____ Zip Code_________ Phone______________________
Immediate supervisor’s name:________________________________ May we contact for a reference?_____
Beginning Salary:________________ Ending Salary:_________________
Position Held:______________________________________________
Reason for Leaving (please explain):_____________________________________________________________
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Employer ________________________________ Employed from: Mo./Yr to Mo./Yr.____________________
Address___________________________________________________________________________________
City________________________________ State_____ Zip Code_________ Phone______________________
Immediate supervisor’s name:________________________________ May we contact for a reference?_____
Beginning Salary:________________ Ending Salary:_________________
Position Held:______________________________________________
Reason for Leaving (please explain):_____________________________________________________________
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Employer ________________________________ Employed from: Mo./Yr to Mo./Yr.____________________
Address___________________________________________________________________________________
City________________________________ State_____ Zip Code_________ Phone______________________
Immediate supervisor’s name:________________________________ May we contact for a reference?_____
Beginning Salary:________________ Ending Salary:_________________
Position Held:______________________________________________
Reason for Leaving (please explain):_____________________________________________________________
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Employer ________________________________ Employed from: Mo./Yr to Mo./Yr.____________________
Address___________________________________________________________________________________
City________________________________ State_____ Zip Code_________ Phone______________________
Immediate supervisor’s name:________________________________ May we contact for a reference?_____
Beginning Salary:________________ Ending Salary:_________________
Position Held:______________________________________________
Reason for Leaving (please explain):_____________________________________________________________
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PROFESSIONAL REFERENCES
List professional references that are familiar with the quality of your work, have worked directly with you, and have known you at least two years.
Name_____________________________________________________________________________________
Phone (work) __________________________________ Phone (Home________________________________
Address ___________________________________________________________________________________
City ___________________ State _______ Zip Code____________
Relationship_________________________________
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Name_____________________________________________________________________________________
Phone (work) __________________________________ Phone (Home________________________________
Address ___________________________________________________________________________________
City ___________________ State _______ Zip Code____________
Relationship_________________________________
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Name_____________________________________________________________________________________
Phone (work) __________________________________ Phone (Home________________________________
Address ___________________________________________________________________________________
City ___________________ State _______ Zip Code____________
Relationship_________________________________
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DRIVING RECORD
Driver’s license no:__________________________ State of Issue:________ Expiration Date:______________
Any restrictions?__________________
The City of Pomeroy will also check your State driving records.
Have you had any driving accidents during the past three years? YES NO (please circle your answer)
If yes, how many? ________
Have you had any moving violations during the past three years? YES NO (please circle your answer)
If yes, how many? ________
CRIMINAL HISTORY
Have you ever been convicted of a criminal offense? YES NO
If your answer was YES, please give the date of the incident, sentencing information and explain the specific nature of the criminal offense:_______________________________________________________________
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If necessary, attach a separate sheet of paper for additional information regarding employment history or other information requested in this application.
PLEASE READ CAREFULLY AND SIGN
BACKGROUND INVESTIGATION AND RELEASE: The information contained in this application is true to the best of my knowledge and belief. I understand that any misrepresentation or omission of fact, as stated or implied, in my application, other employment documents or interview(s) may be sufficient reason for not hiring me and/or dismissal.
EMPLOYMENT “AT-WILL” AGREEMENT: Further, I understand my employment with the City of Pomeroy is on an “at-will” employment basis and thus agree that my employment is for an indefinite period and may be terminated at any time, for any reason, with or without cause, by me or the employer without prior notice. I further understand and agree that this “at-will” relationship will remain in effect throughout my employment with the City of Pomeroy. I understand that the City of Pomeroy is not obligated to provide employment and that I am not obligated to accept employment. Nothing in this application, or in any prior or subsequent oral or written statement, is intended to create any contract of employment or to create any rights in the nature of a contract of employment. This application does not bind either party for a specific period of time regarding employment.
DRUG POLICY: I understand that possession, use, sale, purchase, or being under the influence of illegal/legal drugs on the job will result in termination of employment. All City of Pomeroy buildings are non-smoking environments.
NOTICE TO APPLICANTS: I certify that the information supplied in this application, including any attachment or resume, is true and correct to the best of my knowledge. I understand that falsification of any information contained in this application is grounds for dismissal in accordance with the City of Pomeroy’s “at-will” employment policy. I authorize the references and employers listed to provide the City of Pomeroy with any and all information requested concerning my current and/or previous employment and release all parties from any and all liability for any damage that may result from furnishing this information to the City of Pomeroy.
I understand that my employment can be terminated, with or without cause, and with or without notice, at any time, at the option of either the City of Pomeroy or myself.
I understand that if the position for which I am applying requires a CDL endorsement, I will be required to take a drug test. Employment with The City of Pomeroy is contingent on the NEGATIVE results of the drug screens. I understand that if the results are POSITIVE, the City reserves the right to withdraw any offer and/or terminate employment.
Also, I understand and authorize the City of Pomeroy to perform a background investigation including any criminal conviction records, to contact the references as listed on this application, and to verify professional licenses, certificates and related training or education including military training or experience.
I also authorize the City of Pomeroy to perform a check on my driving record, only ID required by the position for which I am applying. I understand that any job offer made to me is contingent on the results of the driving record. Also, if the position for which I am applying requires driving, a check will be conducted on my driving record on an annual basis. I understand that if my record reveals a violation that relates to my suitability for employment, the City of Pomeroy reserves the right to withdraw any offer and/or terminate employment.
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Applicant’s signature Date