Form

Town of Golden Meadow

Employment Application
Applicant Information
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Desired Salary
Are you a citizen of the United States?

YesNo
If no, are you authorized to work in the U.S.?

YesNo
Have you ever worked for this company?

YesNo
If yes, when?
Have you ever been convicted of a feonly?

YesNo
If yes, explain?

Education
High School
Address
From - To
Did you graduate?

YesNo
College
Address
From - To
Did you graduate?

YesNo
Degree
Other
Address
From - To
Did you graduate?

YesNo
Degree

References

Please provide three professional references
Full Name
Relationship
Company
Address
Phone Number
Please enter a valid phone number.
Full Name
Relationship
Company
Address
Phone Number
Please enter a valid phone number.
Full Name
Relationship
Company
Address
Phone Number
Please enter a valid phone number.

Military Service
Branch
From - To
Rank at Discharge
Type of Discharge
If other than honorable, explain

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I am willing and certain that I can pass a pre-employment drug test. I understand if I fail the drug test for any reason, I am responsible for the cost of the test, at a cost of $55.00 and I will be refused any employment.

I fully understand that if I terminate my employment with the Town of Golden Meadow within 90 days of my date of employment, I will be liable for the cost of my physical exam at a cost of $45.00 and a drug test at a cost of $55.00.
Signature

Clear
Should be Empty: