Employment Application Form

Position Sought*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / County

Postal / Zip Code

Phone Number*

S.S Number*

use no dashes

Birth Date*

MonthDayYear

Email*

example@example.com

Resume and Files

EMPLOYMENT HISTORY & WORK EXPERIENCE

IN THIS SECTION LIST ALL EMPLYMENT HISTORY & WORK EXPERIENCE IN DATE ORDER. BEGIN WITH YOUR CURRENT EMPLOYER. FAILURE TO INCLUDE ALL EMPLOYMENT MAY BE GROUNDS FOR DISQUALIFICATION

Current Employer*

Enter "None" if unemployed

May we contact your current employer prior to employment*

YESNO

Address*

Phone Number*

Dates Employed*

Job Title*

Supervisors Name*

Beginning Salary*

Current Salary*

Describe your duties, responsibilities, equipment operated, promotions, etc..*

Previous Employer*

Enter "None" if unemployed

Address*

Phone Number*

Dates Employed*

Job Title*

Supervisors Name*

Salary at time you left*

Describe your duties, responsibilities, equipment operated, promotions, etc..*

Why did you leave?*

Previous Employer*

Enter "None" if unemployed

Address*

Phone Number*

Dates Employed*

Job Title*

Supervisors Name*

Salary at time you left*

Describe your duties, responsibilities, equipment operated, promotions, etc..*

Why did you leave?*

Previous Employer*

Enter "None" if unemployed

Address*

Phone Number*

Dates Employed*

Job Title*

Supervisors Name*

Salary at time you left*

Describe your duties, responsibilities, equipment operated, promotions, etc..*

Why did you leave?*

EDUCATION & TRAINING

THIS SECTION IS INTENDED TO GIVE THE EMPLYER IMFORMATION ABOUT THE EDUCATION & TRAINING THAT THE APPLICANT HAS COMPLETED. AND TO DEMONSTRATE THE SKILLS, KNOWLEDGE, AND ABILITIES OF THE APPLICANT TO PERFORM THE JOB DUTIES OF THE POSITION

High School Attended*

Address*

Did you graduate or get a GED*

YESNO

Courses pertaining to job applied for*

Activities, Awards, Sports, Etc...*

College or Trade School Attended

Address

Dates of Attendance

Did you graduate

YESNO

Degree

Courses Pertaining to Job Applied For

Activities, Awards, Sports, Etc...

Graduate School Attended

Address

Dates of Attendance

Did you graduate

YESNO

Degree

PLEASE USE THE FOLLOWING SPACE TO PROVIDE ANY FURTHER INFORMATION ON TRAINING, EDUCATION, SKILLS, ABILITIES, HOBBIES, VOLUNTEER WORK, ETC... THAT YOU POSSES OR HAVE EXPERIENCED THAT MAY BE HELPFUL IN THE EVALUATION OF YOUR APPLICATION

PERSONAL INFORMATION

Do you have any commitments (I.E. Second Job, School, Etc..) which might interfere with, or adversely affect your employment should we select you for a position*

YESNO

If Yes, Please Explain

Have you ever been convicted of a felony*

YESNO

If Yes, Please Explain

Do you possess a valid drivers license?*

YESNO

If No, can you obtain one prior to employment?*

YESNO

Are you eligible to work in the United States?*

YESNO

Are you a resident of Ohio?*

YESNO

If not, are you willing to become a resident upon employment?*

YESNO

Are you related to anyone that is currently employed by the village of New Washington*

YESNO

REFERENCES

PLEASE LIST THREE (3) REFERENCES WHO ARE NOT RELATED TO YOU THAT YOU HAVE KNOWN AT LEAST ONE (1) YEAR*

PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. INDICATE YOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH ONE. iF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE INITIALING.

I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol, or substance abuse testing.*

Initials

I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.*

Initials

I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activities.*

Initials

I hereby authorize the employers, schools, and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic, and other records to the employer.*

Initials

If you are hired, this application will become part of your official employment record.*

Initials

I understand and accept that if I am hired, it will be my responsibility to read and understand all written policies, directives, and SOP's; and that I will be disciplined for violating them.*

Initials

I understand that discriminatory harassment (harassing conduct based on race, color, sex, national origin, age, religion, military status, or disability) and sexual harassment are prohibited by law, and I understand and accept that I will be fired if I engage in prohibited harassing behavior.*

Initials

I understand that all information that comes into my possession is to be regarded as confidential, and that I may not copy any records for my own use within written permission, on pain of termination.*

Initials

READ CAEFULLY BEFORE SIGNING

i SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURAT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE. i AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIVED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TEMINATION FOLLOWING EMPLOYMENT.

i ALSO RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE.

FINALLY, I AGREE THAT ANY CLAIM OR LAWSUIT RELATED TO MY SERVING WITH THE VILLAGE OF NEW WASHINGTON MUST BE FILED NO MORE THAN SIX (6) MONTHS AFTER THE DATE OF THE EMPLOYMENT ACTION THAT IS THE SUBJECT TO THE CLAIM OR LAWSUIT. I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.

Signature*

THE VILLAGE OF NEW WASHINGTON APPLICATION FOR EMPLOYMENT