Summit Park District Employment Application

Summit Park District Employment Application

Please complete all required fields and review your information before submitting.
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Driver’s License Number
DL State
DL Expiration Date

MonthDayYear
Date
Is your driver’s license valid?
Restrictions
Are you over 18?
Are you legally authorized to work in the United States?
How did you learn of this opening?
Have you ever applied here before?
When did you apply before?

MonthDayYear
Date
Have you ever worked here before?
When did you work here?

MonthDayYear
Date
Languages spoken/written fluently other than English

Other
Have you ever been convicted of any felony?
Have you ever been convicted of a misdemeanor involving dishonesty, criminal sexual conduct, assault or battery, or any criminal drug statute?
If yes, please describe
Employment Desired
Position Applying For
Available Start Date

MonthDayYear
Date
Are there any days or hours you would be unable or unwilling to work?
If yes, please specify days/hours
Education and Military Service
Education History
Are you a veteran of the U.S. Military?
Branch
Rank
Are you currently, or have you been, in the National Guard or Reserves?
Education and Military Service Instructions
Personal References
Reference 1 Name

First NameLast Name
Reference 1 Occupation & Relationship
Reference 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Name

First NameLast Name
Reference 2 Occupation & Relationship
Reference 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3 Name

First NameLast Name
Reference 3 Occupation & Relationship
Reference 3 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employment History
Please provide at least three employment history entries.
Employer #1

NamePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Your Title
Your Duties
What did you like most about your position?
What did you least like about your positon?
Reason for leaving?
May we contact this employer:
Employment Start Date & End Date
Looking for part time or full time
Last Salary (per hour)
Employer #2

NamePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Your Title
Your Duties
What did you like most about your position?
What did you least like about your positon?
Reason for leaving?
May we contact this employer:
Employment Start Date & End Date
Looking for part time or full time
Last Salary (per hour)
Employer #3

NamePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Your Title
Your Duties
What did you like most about your position?
What did you least like about your positon?
Reason for leaving?
May we contact this employer:
Employment Start Date & End Date
Looking for part time or full time
Last Salary (per hour)
Additional Information
Explain any gaps in employment
Have you ever been fired or asked to resign?
If yes, please explain
Have you ever received attendance-related discipline or discharge?
If yes, please explain attendance-related discipline or discharge
Have you ever received discipline for theft or unauthorized removal of property?
If yes, please explain theft or unauthorized removal discipline
Have you ever received discipline for fighting or assault?
If yes, please explain fighting or assault discipline
Have you ever received discipline for alcohol or drug-related issues?
If yes, please explain alcohol or drug-related discipline
Have you ever received discipline for insubordination?
If yes, please explain insubordination discipline
Have you ever received discipline for safety rule violations?
If yes, please explain safety rule violations
Are you capable of performing the essential job duties with or without accommodation?
Why are you interested in working for our agency, and what skills qualify you?
Applicant Statement and Signature
This is an employment application acknowledgment and authorization statement. By signing it, the applicant is confirming and agreeing to the following:
- All information provided during the hiring process is truthful and complete.
- Summit Park District may verify employment history, references, education, licenses, and other background information.
- The applicant releases Summit Park District and information providers from liability for lawful background verification activities.
- The Park District is an equal opportunity employer and does not discriminate unlawfully.
- The application remains active for one year unless the applicant reapplies.
- Employment, if offered, is “at will,” meaning either the employee or the Park District may terminate employment at any time, with or without cause or notice, unless otherwise required by law.
- No verbal promises or unofficial agreements change the at-will employment relationship unless signed in writing by the Executive Director.
- Employees must provide proof of identity and work authorization and complete an I-9 form.
- False or misleading information may result in disqualification or termination.
Applicant Signature
Date

MonthDayYear
Date
Application Statement
I certify that all information I have provided in order to apply for and secure work with the Summit Park District is true, complete and correct.

I expressly authorize without reservation, the Summit Park District, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies,
licensing authorities and educational institution and to otherwise verify the accuracy of all information provided
by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have
regarding the Summit Park District, its agents, employees or representatives, for seeking, gathering and using
truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons,
corporations or organizations for furnishing such information about me.

I understand that the Summit Park District does not unlawfully discriminate in employment and no question on
this application is used for purpose of limiting or eliminating any applicant from consideration for employment
on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current only for 1 year. At the conclusion of that time, if I have not
heard from the employer and still wish to be considered for employment, it is necessary for me to reapply and
fill out a new application.

If I am hired, I agree to conform to the Summit Park District’s rules and regulations, and I understand I am free
to resign at any time, with or without a cause and with or without a prior notice, and the Summit Park District
reserves the same right to terminate my employment at any time, with or without a cause and with or without prior notice, except where required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the Summit Park District is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by the
Summit Park District Executive Director. I also understand and agree that the terms and conditions of my employment may be changed, with or without a cause, and with or without notice at any time by the Park District.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to eliminate me from further consideration for employment or may result in my
immediate discharge from the Summit Park District’s service, wherever it is discovered.

Do not sign until you have read the above applicant statement.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Signature
Date

MonthDayYear
Date
Authorization for Release of Personal Information
I request, authorize and consent, without reservation, to the release of information to the Summit Park District from all references ( personal and professional) regarding my previous employment and authorize all past employers or agents which the Summit Park District may designate, to respond to oral or written inquiries from the Summit Park District regarding my employment record, including, but not limited to, positions held, dates of employment, last pay raise, work performance,
disciplinary records, liability incidents of dishonesty, insubordination, violence, and/or unsafe, harmful, or threatening
behavior.

In order to determine my fitness for employment with the Summit Park District, I agree to submit to an independent medical examination which shall include drug and alcohol testing, and I agree to submit to psychological examination.

I do knowingly, freely and voluntarily release, remise and discharge the Summit Park District, each member municipality, and the respective boards of the member municipalities at the Summit Park District, their agents, officers, representatives, elected officials, employees and independent contractors, from any and all liability claims, cause of action or damages arising out of, or as a result of, any written or oral inquiry or any information provided or released, as a result of any written or oral inquiry, or from my submission to the medical examination, drug and alcohol testing or psychological examination referenced herein. I assume all risk of loss or damages for testing, release of information or administering or taking of the examinations or tests. I also release any and all of my former employers, and their representatives, employees or the like, from any and all liability which may result from the information supplied by them to the Summit Park District.

I hereby certify that any and all statements made as a part of my employment submission or application to the Summit Park District are true and correct and I agree and understand that any misstatement of material fact made by me in the application process will cause a forfeiture of my part of employment with the Summit Park District on such terms as may be determinedsolely by the Summit Park District and its Board. If I am employed by the Summit Park District, I agree to provide any and all additional documentation necessary for employment with the Summit Park District.
Signature
Date

MonthDayYear
Date
Should be Empty:

Summit Park District Employment Application

Personal Information

Employment Desired

Education and Military Service

Personal References

Employment History

Additional Information

Applicant Statement and Signature

Application Statement

Authorization for Release of Personal Information