"Employment Application Form" - City of Seymour, Indiana

Employment Application Form is a legal document that was released by the Human Resource Department - Seymour City, Indiana - a government authority operating within Indiana. The form may be used strictly within City of Seymour.

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Download "Employment Application Form" - City of Seymour, Indiana

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City of Seymour
Employment Application Form
If you need assistance completing this form, assistance will be provided.
Equal Opportunity Employer – Discrimination in employment because of race, religion, creed, color,
national origin, ancestry, age, sex, or liability for service in the Armed Forces of the United States is
prohibited by City policy. In addition, the City employment policy requires compliance with national and
state employment practices, laws, and regulations. The City of Seymour is an equal opportunity employer.
Name:
Date:
Last
First
Middle
Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Social Security Number:
General Information
Are you 18 years or older?
O Yes
O No
If no, state age:
What type of Drivers License do you hold? O None O Operators
O Commercial
O Other
Has the City of Seymour ever employed you?
O Yes O No
If yes, state department(s) and date(s):
Do you have relatives working for the City of Seymour, in the department for which you are applying?
Have you ever pled guilty to or been convicted of a felony?
O Yes O No
If yes, explain. (Note: This answer will be considered only as it relates to fitness to perform the job)
Are you seeking work:
O Full-time
O Part-time
O Temporary
Position (s) applying for:
If not applying for a specific position, indicate other preferred job (check one area below):
O Officials & Administrators
O Technician
O Clerical / Office
O Professional
O Skilled Craft
O Laborer
Education
School
Name & Location
Last year
Major
Did you
Completed
Graduate?
Grade
School
High
School
Technical
College
Other
Other education related information:
Military Data
Dates of Service:
From:
To:
City of Seymour
Employment Application Form
If you need assistance completing this form, assistance will be provided.
Equal Opportunity Employer – Discrimination in employment because of race, religion, creed, color,
national origin, ancestry, age, sex, or liability for service in the Armed Forces of the United States is
prohibited by City policy. In addition, the City employment policy requires compliance with national and
state employment practices, laws, and regulations. The City of Seymour is an equal opportunity employer.
Name:
Date:
Last
First
Middle
Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Social Security Number:
General Information
Are you 18 years or older?
O Yes
O No
If no, state age:
What type of Drivers License do you hold? O None O Operators
O Commercial
O Other
Has the City of Seymour ever employed you?
O Yes O No
If yes, state department(s) and date(s):
Do you have relatives working for the City of Seymour, in the department for which you are applying?
Have you ever pled guilty to or been convicted of a felony?
O Yes O No
If yes, explain. (Note: This answer will be considered only as it relates to fitness to perform the job)
Are you seeking work:
O Full-time
O Part-time
O Temporary
Position (s) applying for:
If not applying for a specific position, indicate other preferred job (check one area below):
O Officials & Administrators
O Technician
O Clerical / Office
O Professional
O Skilled Craft
O Laborer
Education
School
Name & Location
Last year
Major
Did you
Completed
Graduate?
Grade
School
High
School
Technical
College
Other
Other education related information:
Military Data
Dates of Service:
From:
To:
Employment History
Most recent experience first – Include ALL employers for the past four years. Explain any gaps in
employment.
1. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
2. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
3. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
4. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
May we contact the employers listed above?
O Yes
O No
Personal References
Please list three individuals who are not related to you, do not live with you, and have known you for three
years.
Name
Address
Telephone Number
Relationship
How long have
you known this
person?
Additional Information
Can you show proof of eligibility to work in the U.S.?
O Yes
O No
If offered employment with the City, federal law will require you, to furnish documents showing you are
eligible to work in the U.S. Individuals who do not furnish these documents cannot work for the City.
I authorize anyone whom request is made to supply the City any information concerning my background in
connection with employment consideration. I hereby release all parties, including but not limited to the
City and my prior employers, from any and all liability for any damage that may result from their
furnishing information concerning me. I understand falsification, misrepresentation, incomplete
information, or omission of facts called for on this application will result in dismissal.
I understand and hereby acknowledge that if I am offered and accept employment with the City, my
employment and compensation may be terminated with or without cause and with or without notice at any
time at the option of the City. I further understand that this application for employment is not a contract of
employment.
Signature:
Date:
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