City of Centralia Employment Application

Employment Application

The City of Centralia is an equal opportunity employer. Applicants will be considered regardless of race, color, national origin, religion, gender, age, marital status, veteran status, medical condition, disability, or any other legally protected status. Equal access to the hiring process, services, and employment is available to all individuals. Applicants requiring accommodations to the application and/or interview process should contact the City Clerk.

Each question should be answered completely and accurately.

No action will be taken on this application until all questions have been answered and the application has been electronocally signed and dated. Verification of eligibility to work in the U.S. will be required if an employment offer is made.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Confirmation Email

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver’s license, birth certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination. Employer participates in the E-Verify program.

Position(s) applying for*

Wage expectations*

Salary or Hourly?*

Referral source

Are you over the age of 18?*

YESNO

Are you eligible to work in the United States?*

YESNO

Are you fluent in a foreign language?*

YESNO

If yes, what language(s)?*

Are you currently employed?*

YESNO

Date available for work*

MonthDayYear

Are you available to work?*

Full timePart timeShift workTemporary

Have you applied here before?*

YESNO

If yes, give date:*

Have you been convicted of a felony/misdemeanor (other than traffic violations)?*

YESNO

If so, provide the location, date and result/outcome for each conviction:*

EDUCATION

Highest level of education completed:*

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY

Please list your four most recent employers, list the most recent first

1. Employer

Employer's Name (Most current)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Area CodePhone Number

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

2. Employer

Employer's Name (Second most recent)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Area CodePhone Number

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

3. Employer

Employer's Name (Third most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

4. Employer

Employer's Name (Fourth most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

ADDITIONAL INFORMATION

Do you have a U.S. military service record?*

YESNO

Click to edit

If yes, branch of service*

Discharge date and rank*

List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)

List any additional information you would like us to consider:

Do you have a valid Missouri Driver's License?*

YesNo

Do you have a valid Missouri Commercial Driver's License (CDL)*

YesNo

If you do have a valid Missouri CDL, choose the classification and endorsements you have.

REFERENCES

List two professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.

1. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Area CodePhone Number

Years acquainted*

Relationship*

2. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Area CodePhone Number

Years acquainted*

Relationship*

AUTHORIZATION

I understand that the City of Centralia, Missouri is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed.

I authorize the City of Centralia, Missouri to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. If applying for a commissioned position with the City, I understand that the Missouri P.O.S.T. Commission will be contacted to verify certification and POST hours. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to the City of Centralia, Missouri. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original.

Pre-employment testing will be required (drug testing, background checks, physical examinations, motor vehicle checks). I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made.

I understand that this application is current for 90 days. At the conclusion of this time, if I have not heard from the City of Centralia, Missouri and still wish to be considered for employment, it will be necessary to complete a new application.

I understand that if hired, employment is at-will and may be terminated by myself or the City of Centralia, Missouri at any time, with or without cause or notice, for any reason or no reason.

By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree

You must agree to accept the terms of the document in order to submit an application.

Type signature*

Date*

MonthDayYear

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