Application for Employment

APPLICATION FOR EMPLOYMENT

CITY OF MOUNT PLEASANT, TENNESSEE
The City of Mount Pleasant is an Equal Opportunity Employer and does not discriminate on the basis of race, gender, color, religion, national origin, age, disability, genetic information or veteran status in employment opportunities & benefits.

This application is one part of the hiring and employment process. Other parts may include an interview, an employment examination or test, and a demonstration of an ability to perform the essential functions of the job.

Prior to completing this application read the Job Description of the position for which you are applying. As you complete this application, please bear in mind the following:
- We reserve the right to check all information for accuracy and completeness;
- All applications for employment are a matter of public record pursuant to TCA 10-7-503;
- If you need accommodation to complete this application, please notify the Human Resources Department at 931-379-7717.
All offers of employment extended by the City of Mount Pleasant are conditional upon acceptable results from a post-offer medical examination and drug test. Employees of the City of Mount Pleasant are subject to periodic medical examinations, drug and alcohol testing for cause. Safety sensitive employees are subject to random drug and alcohol testing.
GENERAL INFORMATION
Application Date

MonthDayYear
Date
Position
ARE YOU APPLYING FOR

FULL TIMEPART TIME
IF PART TIME, WHAT DAYS / HOURS ARE YOU AVAILABLE?
HAVE YOU EVER BEEN EMPLOYED BY THE CITY OF MOUNT PLEASANT?*

YESNO
IF YES, PLEASE INDICATE POSITION, DEPARTMENT AND DATES OF EMPLOYMENT:
PERSONAL DATA
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
HOME PHONE
Format: (000) 000-0000.
CELL PHONE*
Format: (000) 000-0000.
EMAIL*
example@example.com
DO YOU HAVE A LEGAL RIGHT TO WORK IN THE U.S.?*

YESNO
OVER 18 YEARS OF AGE?*

YESNO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?*

YESNO
(NOTE: THIS MAY BE RELEVANT IF JOB-RELATED; HOWEVER DOES NOT BAR YOU FROM EMPLOYMENT)
IF YES,PLEASE EXPLAIN:
EDUCATION AND TRAINING
HIGH SCHOOL
HIGH SCHOOL ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
GED

YESNO

Additional Education

Rows	COLLEGE / UNIVERSITY TRADE / BUSINESS SCHOOL	CITY / STATE / ZIP	DEGREE EARNED	AREA OF STUDY

LIST OTHER TRAINING RECEIVED SPECIAL COURSES, WORK TRAINING PROGRAM, ARMED FORCES TRAINING ETC
LIST SPECIAL QUALIFICATION AND SKILLS LICENSES, SKILLS WITH MACHINES, PATENTS OR INVENTIONS, PUBLICATIONS, ETC
WORK EXPERIENCE
HOW MANY PREVIOUS EMPLOYERS HAVE YOU HAD?

NONEONETWOTHREE OR MORE
EMPLOYER
PHONE
Format: (000) 000-0000.
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
JOB TITLE
SUPERVISOR
WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
STARTING SALARY
ENDING SALARY
MAY WE CONTACT THIS EMPLOYER?

YESNO
EMPLOYER
PHONE
Format: (000) 000-0000.
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
JOB TITLE
SUPERVISOR
WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
STARTING SALARY
ENDING SALARY
MAY WE CONTACT THIS EMPLOYER?

YESNO
EMPLOYER
PHONE
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
JOB TITLE
SUPERVISOR
WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
STARTING SALARY
ENDING SALARY
MAY WE CONTACT THIS EMPLOYER?

YESNO
REFERENCES
LIST THREE PERSONS, OTHER THAN RELATIVES OR FORMER EMPLOYERS, WHO HAVE KNOWLEDGE OF YOUR CHARACTER AND / OR ABILITIES:
NAME
YEARS KNOW
PHONE
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
NAME
YEARS KNOW
PHONE
Format: (000) 000-0000.
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
NAME
YEARS KNOW
PHONE
Format: (000) 000-0000.
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
APPLICANT'S AGREEMENT AND CERTIFICATION
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I understand that falsified information or significant omissions may disqualify me and my application from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide any information orally and/or in writing to the City of Mount Pleasant that may be requested to arrive at an employment decision and waive any right of privilege, privacy and/ or confidentiality I may have in this information.
Signature*
DATE

MonthDayYear
Date
BACKGROUND INVESTIGATION AUTHORIZATION
Name*

First NameMiddle NameLast Name
SOCIAL SECURITY NUMBER*
ADDRESS:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE
Format: (000) 000-0000.
CELL PHONE*
Format: (000) 000-0000.
DRIVER'S LICENSE # & STATE ISSUED*
OTHER NAME (S)
YEAR OF NAME CHANGE
RESIDENTIAL ADDRESSES (PREVIOUS 7 YEARS)
PREVIOUS ADDRESSES IN THE LAST 7 YEARS:

NONE (ONLY LIVED AT ADDRESS ABOVE)ONETWOTHREE OR MORE
FORMER ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
FORMER ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
FORMER ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
HAVE YOU BEEN CONVICTED OF ANY CRIMINAL OFFENSE, EITHER MISDEMEANOR OR FELONY, OTHER THAN YESNO MINOR TRAFFIC VIOLATIONS IN THE LAST 7 YEARS?*

YESNO
ARE YOU CURRENTLY CHARGED OR UNDER INVESTIGATION FOR ANY VIOLATION OF THE LAW OTHER THEN YESNO MINOR TRAFFIC VIOLATIONS?*

YESNO
AUTHORIZATION AND GENERAL RELEASE
I hereby authorize the City of Mount Pleasant its representatives, employees or agents to contact and obtain any information and records concerning me, including but not limited to consumer, criminal record history, driving, employment, military and educational data and reports, from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies, consumer reporting agencies and other entities, including my present and previous employers.

I further release and discharge the City of Mount Pleasant and all of its affiliates, and every employee or agent, and all individuals and personal, business, private or public entities of any kind, from any kind, from any and all claims and liability arising out of any request(s) for, or receipt of, information or records pursuant to this authorization, or arising out of any compliance or attempted compliance, with such request(s).

I also authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics and mode of living, whichever are applicable. I understand that I have the right to make a written request within a reasonable period of time to the City of Mount Pleasant for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided for employment purposes the above information, and I have carefully read and I understand this authorization.

NOTICE: The City of Mount Pleasant requests your date of birth solely for the purpose of verifying certain records that may be produced in connection with the City of Mount Pleasant background investigation. It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statues, regulations and ordinances.
Signature*
DATE

MonthDayYear
Date
Should be Empty:

APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION

PERSONAL DATA

EDUCATION AND TRAINING

WORK EXPERIENCE

REFERENCES

APPLICANT'S AGREEMENT AND CERTIFICATION

BACKGROUND INVESTIGATION AUTHORIZATION

ADDRESS:

RESIDENTIAL ADDRESSES (PREVIOUS 7 YEARS)

AUTHORIZATION AND GENERAL RELEASE