CITY OF BLACKWELL EMPLOYMENT

Position Desired
Date of Application

Month Day Year
Date
Date Available For Work

Month Day Year
Are you available to work:

Full Time Part Time Shifts Weekend Nights
Name
Middle
Lastname
Street Address
City, State, Zip
Home Phone
Cell Phone
Please enter a valid phone number.
Business Phone
Email Address
example@example.com
If you are under 18 years of age, can you provide proof of your eligibility to work?(Verification will be required upon employment and failure to furnish documentation will be cause for separation.)

Yes No
Do you hold a current and valid Driver's License?

Yes No
Do you hold a current and valid CDL License (with endorsements specific to the equipment you will be operating)? If so, give type, expiration date, and number: (If tentatively selected, applicant applying for position where driving is required, will be required to furnish a copy, at their expense, of their driving record prior to employment.}

Yes No
Are you related to any city employee or any member of City Commission?If so, give name, department, and relationship: *

Yes No If So...
Have you been convicted of a felony in the last 7 years or are you currently charged with the commission of a felony? If yes, state what, when and how: (Note: this information does not in itself disqualify you for employment):

Yes No

REASONABLE ACCOMMODATION
After reviewing the essential job functions from the job description, are you able to do the work with or without reasonable accommodation?

Yes No
The City is concerned with your ability to perform the job and will not at this time consider your need for reasonable accommodation. If after reviewing your application form, verifying your responses, and conducting necessary interviews or tests, you are considered for the job and would need reasonable accomdation to perform the essential job functions, the parties will explore these alternatives.

REMEMBER: The City conducts a pre-employment exam which will determine whether you can do the essential functions of the Job without substantial risk to yourself and the public.

In addition, review the minimum qualifications and provide us with prior education, work experience, and any relevant training or certificates and licenses that would indicate your knowledge, skills, and abilities to perform the job. Be as specific as possible since you will be screened on what you include regardless of what you might otherwise be able to perform.

Give name, address, and telephone number of three references who are not related to you and are not previous employers.

ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
If you have any additional information or comments concerning any voluntary experience, and special licenses or training which would help us determine your suitability for this position, please use the space provided below or an extra sheet of paper if necessary. All attachments must be signed.

Read Carefully Before Signing I certify that facts given in this application are true and complete to the best of my knowledge. I hereby grant permission to the City of Blackwell to investigate any information included in the application and I agree to submit to medical examination if required. I understand that this application is not a contract of employment. I hereby release the City and its agents from all liability in making any investigation and inquiry relative to information contained in the application form. I understand, that if employed, false or misleading statements given in this application or interview(s) may result in discharge. I understand that I am required to abide by all rules and regulations of the City of Blackwell.
Signature

Clear
Date

Month Day Year
Date
For Office Use Only: This section to be completed by interviewer before application is returned to Personnel/City Manager.
Should be Empty:

Military Service