City of Benton application

CITY OF BENTON

Human Resources Department

410 River Street, Benton, AR 72015

PO 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 applying for:
Other position:
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2
CityStateZip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Cell)
Please enter a valid phone number.
Phone Number (Business)
Please enter a valid phone number.

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 410 River Street, Benton, AR 72015. The request to the Human Resources Department may be in writing, by telephone (501-776-5900), 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.
PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING

I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.
Initials*
I understand, where permissible under applicable state and local law, I may be subject to pre-employment medical examinations after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with the City of Benton.
Initials*
I hereby certify that the information given by me is true in all aspects. I authorize the City of Benton and its representatives to contact my prior employers and all others for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested.
Initials*
I understand employment with the City of Benton is also contingent on my providing sufficient documentation necessary to establish by identity and eligibility to work in the United States.
Initials*
I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at will, with or without cause, by either party (City of Benton or me) without prior notice to the other, unless prohibited by law.
Initials*
I understand that no representation, whether oral or written, by any representative or agent of the City of Benton, at any time, can constitute an implied or expressed contract of employment. I further understand no representative or agent of the City of Benton has the authority to enter into an agreement for employment for any specified period of time.
Initials*
I certify, under penalty of perjury, that all the above information is true and complete, and I understand that any falsification or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time lapse before discovery.
Note: An offer of employment is conditioned upon complying with the City of Benton’s requirements.
My signature is evidence that I have read and agree with the above statements and all pages included in the application for employment.
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.
Date of Signature*

MonthDayYear
Date
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CITY OF BENTON

Notice to Applicants - Please read carefully!!!