COBapplication

CITY OF BENTON

Human Resources Department

114 S. East Street, Benton, AR 72015

P.O Box 607, Benton, AR 72018

(501)776-5900

www.bentonar.org

The City of Benton is an Equal Opportunity Employer and is committed to providing equal employment opportunity with regard to race, color, religion, national origin, age, sex, sexual orientation, marital or parental status, veteran status, or disability.
Position Applied For:*
Other position:
Date*

MonthDayYear
Date

Education

Education*

	School Name/Location	Did you Graduate?	Major	Degree/Diploma
High School
College/University
College/University
Other training

In addition to your work history, what other experiences, skills or qualifications would especially qualify you for work with the City of Benton? Specify office equipment, machines, computer software, licenses, special training or classes:
If employed in the position for which you have applied, would you be in a direct supervisory relationship (receive supervision or provide supervision) to any relative or member of your household?*

YesNo
If yes, in the space provided below, list the full name(s) of the relative(s) and their relationship to you.
Full Name of Relative / Relationship to you / Department
Full Name of Relative / Relationship to you / Department

References

References*

	Name	Address	Phone #	Occupation
#1
#2
#3

Notice to Applicants - Please read carefully!!!

If you have a disability and require reasonable accommodation in the application and/or testing process, please complete a Reasonable Accommodation Request Form. Forms are available and should be returned to the Benton Human Resources Department at 114 S. East Street, Benton, AR 72015. The request to the Human Resources Department may be in writing, by telephone (501-776-5900 ext. 105 or 106), or in person. To avoid unnecessary delay, please submit your request and documentation of the need for accommodation at least 48 hours in advance of the time accommodation is needed.
Signature*

Clear
I understand that this application is not intended to create any contractual or other legal rights. It does not alter the at-will employment status nor does it create any employment contract. I certify that I have made no willful misrepresentations in this application nor have I withheld information in my statements and answers to questions. I am aware that the information given by me in my application will be investigated, with my full permission, and that any misrepresentations may cause my application to be rejected or my employment to be terminated. I give complete permission to former employers to release to the City of Benton or its authorized representative and and all employment records and other information it may have about my employment. I understand that the information will be used for the purpose of evaluating my application for employment with the city. A photo or digital copy of of this authorization will be as valid as the original. I understand that my appointment will be at the discretion of the department head, subject to the approval of the Mayor or General Manager and that this application is the property of the city and will become part of my file if I am accepted for employment.
Social Security Number*
Driver's License Number*
State*
Date of Signature*

MonthDayYear
Date
Resume Upload (optional)

Cancelof

CITY OF BENTON

BEGIN WITH YOUR PRESENT OR LAST EMPLOYER

Notice to Applicants - Please read carefully!!!

Applicant Information Form