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"Employment Application Form"

Employment Application Form is a 4-page legal document that was released by the U.S. Senate on March 1, 2011 and used nation-wide.

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United States Senate
Phone:
202-224-2889
Fax:
202-228-2965
Office of the Sergeant at Arms
TTY:
202-224-7806
Department of Human Resources
Room 142, Hart Building
Washington, D.C. 20510
Email: resumes@saa.senate.gov
EmploymEnt ApplicAtion Form
Application for Position of
: ______________________________________________________________________________
(All applications must refer to a current position vacancy.)
Name: __________________________________________________________________________________
Mr., Mrs., Ms., Miss (optional)
(Last)
(First)
(M.I.)
Home Address: __________________________________________________________________________
(
Number)
(Street)
(Apt. #)
________________________________________________________________________________________
(City)
(State)
(Zip)
Primary Phone : ________________________
Alternate Phone: ________________________
❏ Home
❏ Cell
❏ Work
❏ Home
❏ Cell
❏ Work
Email Address: __________________________________
Are you a citizen of the United States?* Yes £ No £
* Pursuant to federal law, Senate employees must be U.S. citizens, with some limited exceptions.
Individuals who are entitled to a veterans’ preference are invited to self-identify voluntarily. This
information is intended solely for use in connection with the obligations and efforts of the Office
of the Senate Sergeant at Arms to provide veterans’ preference to preference-eligible applicants
in accordance with the Veterans Employment Opportunities Act of 1998. An applicant’s status as
a disabled veteran and any information regarding an applicant’s disability that the Office of the
Senate Sergeant at Arms obtains, including the applicant’s medical condition and history, will be
kept confidential and will be collected, maintained and used in accordance with the Americans
with Disabilities Act of 1990, as made applicable by section 102(a)(3) of the Congressional
Accountability Act of 1995, 2 U.S.C. § 1302(a)(3). An applicant who declines to self-identify as
a disabled veteran and/or to provide information and documentation regarding his/her disabled
veteran’s status will not be subjected to an adverse employment action, but the applicant may be
ruled ineligible for a veterans’ preference.
Are you self-identifying as veterans’ preference eligible under the VEOA? Yes ___ No ___
Individuals claiming a veterans’ preference must complete an Application for Veterans’ Preference
and must submit applicable documentation. A copy of the Application for Veterans’ Preference
is available at www.senate.gov/saaemployment. A copy of the Office’s Veterans’ Preference in
Appointments policy may be obtained by submitting a written request to resumes@saa.senate.gov.
Reset Page
United States Senate
Phone:
202-224-2889
Fax:
202-228-2965
Office of the Sergeant at Arms
TTY:
202-224-7806
Department of Human Resources
Room 142, Hart Building
Washington, D.C. 20510
Email: resumes@saa.senate.gov
EmploymEnt ApplicAtion Form
Application for Position of
: ______________________________________________________________________________
(All applications must refer to a current position vacancy.)
Name: __________________________________________________________________________________
Mr., Mrs., Ms., Miss (optional)
(Last)
(First)
(M.I.)
Home Address: __________________________________________________________________________
(
Number)
(Street)
(Apt. #)
________________________________________________________________________________________
(City)
(State)
(Zip)
Primary Phone : ________________________
Alternate Phone: ________________________
❏ Home
❏ Cell
❏ Work
❏ Home
❏ Cell
❏ Work
Email Address: __________________________________
Are you a citizen of the United States?* Yes £ No £
* Pursuant to federal law, Senate employees must be U.S. citizens, with some limited exceptions.
Individuals who are entitled to a veterans’ preference are invited to self-identify voluntarily. This
information is intended solely for use in connection with the obligations and efforts of the Office
of the Senate Sergeant at Arms to provide veterans’ preference to preference-eligible applicants
in accordance with the Veterans Employment Opportunities Act of 1998. An applicant’s status as
a disabled veteran and any information regarding an applicant’s disability that the Office of the
Senate Sergeant at Arms obtains, including the applicant’s medical condition and history, will be
kept confidential and will be collected, maintained and used in accordance with the Americans
with Disabilities Act of 1990, as made applicable by section 102(a)(3) of the Congressional
Accountability Act of 1995, 2 U.S.C. § 1302(a)(3). An applicant who declines to self-identify as
a disabled veteran and/or to provide information and documentation regarding his/her disabled
veteran’s status will not be subjected to an adverse employment action, but the applicant may be
ruled ineligible for a veterans’ preference.
Are you self-identifying as veterans’ preference eligible under the VEOA? Yes ___ No ___
Individuals claiming a veterans’ preference must complete an Application for Veterans’ Preference
and must submit applicable documentation. A copy of the Application for Veterans’ Preference
is available at www.senate.gov/saaemployment. A copy of the Office’s Veterans’ Preference in
Appointments policy may be obtained by submitting a written request to resumes@saa.senate.gov.
Reset Page
WorK ExpEriEncE
Please fill out this portion completely. (A resume is not a substitute for an application form, but a resume may be attached
to this form.) Begin with your current or most recent work experience. Attach additional pages, if necessary.
1. _____________________________________________________________________________________
(Name of Employer)
(Your Job Title)
(Dates of Employment)
_________________________________________________________________________________________________________
(Address of Employer)
(Final Salary)
_________________________________________________________________________________________________________
(Name of Supervisor)
(Supervisor's Job Title)
(Telephone Number) (ext.)
Description of Work: _______________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
May we talk to your current employer about your qualifications and record of employment? Yes
No
If not, please explain: ______________________________________________________________________________________
2. _____________________________________________________________________________________
(Name of Employer)
(Your Job Title)
(Dates of Employment)
_________________________________________________________________________________________________________
(Address of Employer)
(Final Salary)
_________________________________________________________________________________________________________
(Name of Supervisor)
(Supervisor's Job Title)
(Telephone Number) (ext.)
Description of Work: _______________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
3. _____________________________________________________________________________________
(Name of Employer)
(Your Job Title)
(Dates of Employment)
_________________________________________________________________________________________________________
(Address of Employer)
(Final Salary)
_________________________________________________________________________________________________________
(Name of Supervisor)
(Supervisor's Job Title)
(Telephone Number) (ext.)
Description of Work: _______________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
Reset Page
4. _____________________________________________________________________________________
(Name of Employer)
(Your Job Title)
(Dates of Employment)
_________________________________________________________________________________________________________
(Address of Employer)
(Final Salary)
_________________________________________________________________________________________________________
(Name of Supervisor)
(Supervisor's Job Title)
(Telephone Number) (ext.)
Description of Work: _______________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
5. _____________________________________________________________________________________
(Name of Employer)
(Your Job Title)
(Dates of Employment)
_________________________________________________________________________________________________________
(Address of Employer)
(Final Salary)
_________________________________________________________________________________________________________
(Name of Supervisor)
(Supervisor's Job Title)
(Telephone Number) (ext.)
Description of Work: _______________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
EducAtion
institution
did you grAduAtE?
FROM
TO
YES
NO
DEgREE / MAJOR
High School ________________________________________________________________________________________________
College or University ________________________________________________________________________________________
Graduate School ____________________________________________________________________________________________
otHEr inFormAtion
1. How did you learn of this position? ___________________________________________________________________________
£
£
2. Does the Senate Sergeant at Arms employ any of your relatives? Yes
No
If yes, provide the name, relationship
and department where the relative works. If multiple relatives are employed, attach additional page(s).
Name: __________________________________
Relationship: ____________________
Department: ___________________
£
£
3. Have you ever been fired, asked to resign or denied reemployment? Yes
No
If yes, provide a detailed explanation
(employer, when, reason, etc.). Attach additional pages if necessary.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Reset Page
£
£
4. Have you ever resigned after being notified of a recommendation to fire you? Yes
No
If yes, provide a detailed
explanation (employer, when, reason, etc.). Attach additional pages if necessary.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
5. Have you ever been convicted of a violation of the law (misdemeanor or felony) other than a minor traffic violation?
£
£
Yes
No
If yes, provide a detailed explanation of every such conviction* (kind of conviction, when, where, outcome,
etc.). Attach additional pages if necessary.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
£
£
6. Are any criminal or non-civil charges or proceedings pending against you?
Yes
No
If yes, provide a detailed
explanation of every such charge or proceeding* (what is the charge, where, when, etc.). Attach additional pages if necessary.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
* When answering these questions, you may omit (a) any offense committed before your 18
birthday which was finally adjudicated
th
in a juvenile court or under a youth offender law, (b) any conviction the record of which has been expunged under federal or
state law, and (c) any conviction set aside under the Federal Youth Corrections Act or similar authority. Being convicted of or
charged with a misdemeanor or felony will not necessarily disqualify an applicant from employment.
cErtiFicAtion And AutHoriZAtion to rElEAsE inFormAtion
I certify that all of the statements made in this application are true, complete, and correct to the best of my knowledge. I
understand that a false answer to any question, or the withholding or omission of any information on this form, may be grounds
for not employing me, or for dismissing me after I begin work.
I hereby authorize any authorized representative of the U.S. Senate Office of the Sergeant at Arms (SAA) bearing this release or a
copy thereof to obtain any background information from schools, employers, criminal justice agencies, or other individuals. This
information may include, but is not limited to, academic, achievement, performance, attendance, disciplinary, and conviction
records. I hereby direct the release of such information upon request of the bearer. I understand that the information released is
for official use by the SAA and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities.
I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature
which may result from their compliance, or any attempts to comply, with this authorization. Should there be any question as to
the validity of this release, you may contact me.
If employed and in consideration of my employment, I understand that I may be subject to drug or alcohol testing and I agree
to conform to the rules and regulations of the SAA and to those of the Senate. I understand that in accordance with the law and
office policy, employees of the SAA are employed at will and that employment can be terminated with or without cause and
with or without notice at any time and at the option of either me or my employer. I understand that no representative of the
SAA has any authority to enter into any agreement of employment for any specific period of time or to make any agreement
contrary to the foregoing.
I understand that I must provide proof of my eligibility for employment in the United States and the Senate.
Signature of Applicant: _____________________________________________
Date: _________________________
The Office of the Sergeant at Arms is an equal opportunity employer
in accordance with the requirements of Senate rules, regulations, and applicable federal laws.
Reset Page
Rev: 03/11
U.S. Senate United States Federal Legal Forms United States Legal Forms

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"Employment Application Form" Download Pdf
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