Town of Bokchito Employment Application

Town of Bokchito, Oklahoma

Application For Employment
PLEASE NOTE: It is important that you complete all parts of the application. If you have no information to enter in a section, please type N/A. The Town of Bokchito is an Equal Opportunity/Affirmative Action Employer.
Name:

First NameMiddle NameLast Name
Date of Birth:
Social Security Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email:
Position Seeking:
I am seeking:

Full-TImePart-TimeFull or Part-Time
Days you are available to work:

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Hours you are available to work:
Are you related to any member of the Board of Trustees?

YesNo
If yes, who and how related:
Are you a US Citizen, permanent resident, or a foreign national with authorization to work in the United States?

YesNo
Have you ever been convicted of, entered a plea of guilty or no contest, or had a withheld judgement to a crime?

YesNo
If yes, give details:
Driver's License Number/State:
Have you had any traffic accidents in the past 3 years?

YesNo
If yes, list details:
Have you had any traffic tickets in the past 3 years?

YesNo
If yes, list details:

EDUCATION:

	Name	Location	Years Completed	Degree or Diploma
High School
College
Business School
Trade School
Other

Have you ever been in the Armed Forces?

YesNo
If yes, list branch and type of discharge:
WORK EXPERIENCE:
Company Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of last supervisor:
Hours worked per week:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Final Salary:
Job Title:
Reason for Leaving:
Company Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of last supervisor:
Hours worked per week:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Final Salary:
Job Title:
Reason for Leaving:
Company Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of last supervisor:
Hours worked per week:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Final Salary:
Job Title:
Reason for Leaving:
Company Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of last supervisor:
Hours worked per week:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Final Salary:
Job Title:
Reason for Leaving:
REFERENCES:

List 3 references. Please include the name, address, phone number and how you know the person. DO NOT INCLUDE RELATIVES OR FORMER EMPLOYERS.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
How you know this person:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
How you know this person:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
How you know this person:
I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any flase or misleading information, my application may be rejected or my employment with the Town of Bokchito terminated.
Signature

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Date

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Date

RELEASE AUTHORIZATION

EMPLOYMENT INFORMATION

As a candidate for a position with the TOWN OF BOKCHITO, I am required to furnish information for use in determining my qualifications. I accordingly authorize, for 120 days from the date I sign this release and waiver, any authorized representative of my prospective employer bearing this release or any copy thereof, to obtain any and all information you have concerning me, including but not limited to, information pertaining to my employment, job applications, performance evaluations, attendance records, disciplinary actions, eligibility for rehire, and other information relevant to my suitability for peace officer employment, including any and all files otherwise deemed confidential or privileged, including any and all materials that have been sealed by agreement, court order, or otherwise, including, but not limited to, disciplinary matters. I acknowledge and understand that when my prior employers, or other persons, provide information to my prospective employer in order for my prospective employer to determine suitability for peace officer employment, that the disclosure of information by my prior employer or other persons to my prospective employer is confidential.

I further understand that when seeking employment with another department or agency employing peace officers in this state, I am required to give written permission to the hiring department or agency to review my general personnel file and any other separate file designated by my agency, including investigations of misconduct.

I hereby acknowledge and understand that certain records or information contained in any of the files, materials or information that may be disclosed to my prospective employer pursuant to this release may be considered confidential by signing this authorization, I hereby voluntarily and irrevocably waive any and all rights to have any record or records or information contained therein discovered or disclosed. and instead, hereby freely and voluntarily authorize the disclosure of all such records, including those records to which, as an employee, the undersigned would have or did have access. I agree that if I am hired, I may choose to have information gathered during the background investigation remain confidential and not become part of my general personnel file.

I hereby release, discharge, and exonerate the agency and/or any person furnishing information pursuant to this release, including their agents and representatives, from liability or damages of any kind arising out of the furnishing and/or inspection of records in compliance with this authorization and request to release information. I hereby waive any and all right and/or opportunity to review, inspect and/or obtain the background investigation report and/or any information provided during the background investigation.

It is further understood, acknowledged, and agreed to, that any information secured pursuant to this required background investigation, which would negatively reflect on my fitness for duty, may be furnished to my current law enforcement employer or other third parties as may be deemed necessary in the course of fulfilling its official responsibilities.

This release shall be binding on my legal representatives, heirs, and assigns.

This authorization to release records is valid for 120 days from the date of signature.
Candidate Printed Name:
Signature

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ADVISEMENT TO CANDIDATE

REGARDING CREDIT INFORMATION FOR EMPLOYMENT PURPOSES

The U.S. Fair Credit Reporting Act (FCRA) [15 U.S. Code 1681, §604(b)] requires that you be notified separately of your rights before any prospective employer may use credit data as part of an employment decision. In some cases, an evaluation of your financial history is mandated by law or by policy of your prospective employer.

You are hereby notified that your prospective employer intends to use credit data as part of its decision-making process for the position for which you have applied. The Credit Reporting Agency (CRA), which will furnish this data, will be TRANSUNION SCREENING SOLUTIONS, INC. located at 6430 S. FIDDLER’S GREEN CIRCLE #500, GREENWOOD VILLAGE, CO 80111. Their telephone number is 1-888-710-0272. You will automatically be furnished a copy of this report, but before any adverse actions are taken as a result of this document, you are advised of the following:

1.       Access to your file is limited to persons recognized by the FCRA;

2.       Your consent is required for reports that are provided to employers or that contain medical information;

3.       You can find out what is in your file, although some information, such as “risk sources” or “credit scores” may be lawfully withheld;

4.       You have been informed of the name, address, and telephone number of the CRA which is furnishing this data;

5.       You can dispute inaccurate information with the CRA;

6.       Inaccurate information must be corrected or deleted;

7.       Outdated information may not be reported (seven years for most information, ten years for bankruptcies);

8.       You may choose to exclude your name from the CRA list for unsolicited credit and insurance offers;

9.       You may seek damages from violators, and;

10.    The complete text of this act may be found at www.ftc.gov.

CERTIFICATION: I certify that the TOWN OF BOKCHITO has my consent to obtain a copy of my credit report for the limited purpose of my pre-employment background investigation; that I have been informed that I will receive a copy of my credit report and that I have been informed in summary form of my rights under the FCRA.
Candidate Printed Name:
Signature

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Town of Bokchito, Oklahoma