City of West Liberty Employment Application

City of West Liberty Employment Application
This City is an equal opportunity employer and does not discriminate against any employee or applicant for employment on the basis of age, race religion, creed, color, sex, national origin, or disability.

Note: If you have a physical or mental disability and you believe that an accommodation may be necessary in order for you to complete this application, please state the kind of accommodation which you may believe is appropriate:
Please answer ALL questions. Print or write carefully. If you provide false, inaccurate, in incomplete information in this application form or in any interview or if you fail to disclose information requested in this application form or any interview, you will not be eligible for employment, or, if you are hired, you will be subject to termination.
Applicant Information

To Be Completed By All Applicants
First Name
Last Name
Today's Date

Month Day Year
Date
Street Address
City
State
Zip Code
Phone
Email
example@example.com
Date Available

Month Day Year
Date
Driver's License
Date of Birth

Month Day Year
Date
Position Applied for
Are you a citizen of the United States?

YES NO
Are you legally eligible to work in the U.S.?

YES NO
Have you ever worked for West Liberty?

YES NO
If so, when?
Have you ever been convicted of a felony?

YES NO
If so, explain:
Motor Vehicle Operator Information

The following 3 questions must be answered in order to complete a check of your driving record: 1. Date of Birth 2. Drivers License Information 3. Traffic Record Conviction
1. Date of Birth

Month Day Year
Date
2. Drivers License Information
State
License #
3) Traffic Record Conviction
Education
High School
Address
From
To
Did you graduate?

YES NO
Degree
College
Address
From
To
Did you graduate?

YES NO
Degree
Other
Address
From
To
Did you graduate?

YES NO
Degree
References

Please list three professional references.
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Previous Employment
Company
Phone
Address
Supervisor
Job Title
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YES NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YES NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YES NO
Military Service
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
Drug and Alcohol Information

For All Applicants
All applicants for employment are required to submit to a drug and alcohol rest after conditional offer of employment has been made. The results of the drug and alcohol tests will be provided to the City. If you are currently using illegal drugs or controlled substances, you are not eligible for employment. If you use illegal drugs or controlled substances after you have been employed, you will be subject to disciplinary action or dismissal. This policy does not apply to the use of medications which have been prescribed for an individual by a licensed medical practitioner and which are used strictly in accordance with the prescription.
FOR ALL APPLICANTS

Please read carefully before signing.
I hereby certify that the statements made by me in this application and all related information which I have provided are true, accurate and complete to the best of my knowledge. I understand that if I provide any false, inaccurate, or incomplete information, I will not be eligible for employment, or, if I am hired, I regardless of the date on which the City discovers the violation of its policy regarding application from dishonesty.

In connection with my application for employment with the City, I expressly authorize the release to the City of any records or information which may refer or relate to my application for employment, including, but not limited to, records of schools, law enforcement or criminal justice agencies, and previous employers. I hereby release and discharge the City and any other person, firm, agency or corporation from any and all claims and liability which I may have or ever claim to have relating to information provided to the City as part of my application for employment.

If I am offered and accept employment with the City, I understand that my employment is At Will and that my employment may be terminated at any time and for any reason either by me or by the City
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

City of West Liberty Employment Application

Applicant Information

Motor Vehicle Operator Information

Education

References

Previous Employment

Military Service

Drug and Alcohol Information

FOR ALL APPLICANTS