"Employment Application Form"

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CITY OF LA JUNTA
PO BOX 489
La Junta, CO 81050
719-384-5991
APPLICATION FOR EMPLOYMENT
It is our policy to comply with all applicable state and federal laws prohibiting discrimination in
employment based on race, age, color, sex, religion, national origin, or other protected
classification. Equal access to programs, services and employment is available to all persons.
Those applicants requiring reasonable accommodation to the application and/or interview
process should notify a representative of the Personnel Department.
Name ____________________________________________________________
Address ___________________________________________________________
Telephone number ___________________ Other Phone number _____________
E-mail _____________________
Have you worked here before? _______
Are you legally eligible for employment in this country? _____________
Are you over 18 years old? ________
Are you willing to work overtime as required? ________
Are there any hours, shifts or days you cannot or will not work?
__________________________________________________________________
Employment desired: Full-Time _____ Part-Time _____ Seasonal ______
Have you ever been bonded? __________
Have you been convicted of a crime in the last 7 years? _____________ If yes,
please explain:
__________________________________________________________________
Conviction will not necessarily be a bar to employment. Each instance and explanation will be
considered in relation to the position for which you are applying.
Driver’s License Number _______________________________________
POSITION APPLIED FOR _____________________________________________________
CITY OF LA JUNTA
PO BOX 489
La Junta, CO 81050
719-384-5991
APPLICATION FOR EMPLOYMENT
It is our policy to comply with all applicable state and federal laws prohibiting discrimination in
employment based on race, age, color, sex, religion, national origin, or other protected
classification. Equal access to programs, services and employment is available to all persons.
Those applicants requiring reasonable accommodation to the application and/or interview
process should notify a representative of the Personnel Department.
Name ____________________________________________________________
Address ___________________________________________________________
Telephone number ___________________ Other Phone number _____________
E-mail _____________________
Have you worked here before? _______
Are you legally eligible for employment in this country? _____________
Are you over 18 years old? ________
Are you willing to work overtime as required? ________
Are there any hours, shifts or days you cannot or will not work?
__________________________________________________________________
Employment desired: Full-Time _____ Part-Time _____ Seasonal ______
Have you ever been bonded? __________
Have you been convicted of a crime in the last 7 years? _____________ If yes,
please explain:
__________________________________________________________________
Conviction will not necessarily be a bar to employment. Each instance and explanation will be
considered in relation to the position for which you are applying.
Driver’s License Number _______________________________________
POSITION APPLIED FOR _____________________________________________________
Employment History
Provide the following information for your past and current employers, assignments or volunteer activities, starting with the
most recent. Explain any gaps in employment in comments below.
Employer
Telephone
Dates Employed
Summarize the type of work
Address
From
To
Performed and job
responsibilities
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference?
$
Per
Employer
Telephone
Dates Employed
Summarize the type of work
Address
From
To
Performed and job
responsibilities
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference?
$
Per
Employer
Telephone
Dates Employed
Summarize the type of work
Address
From
To
Performed and job
responsibilities
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference?
$
Per
Comments
including explanation of any gaps in employment _____________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Skills and Qualifications
- Summarize any special training, skills, licenses and/or certificates that may qualify you as
being able to perform job-related functions in the position for which you are applying.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Educational Background
If job related List last 3 schools attended, starting with most recent.
School
Years Completed
Degree/Diploma
Major
References
List name and telephone number of 3 business/work references who are not related to you and are not
previous supervisors. If not applicable, list 3 school or personal references who are not related to you.
Name
Telephone
Years Known
List special accomplishments, publications, awards, etc.
Exclude information which would reveal sex, race,
religion, national origin, age, color, disability or any other similarly protected status.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List any additional information you would like us to consider ________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I understand that if I am employed, any misrepresentation or material omission made by
me on this application will be sufficient cause for cancellation of this application or
immediate discharge from the employer’s service, whenever it is discovered.
I give the employer the right to contact and obtain information from all references,
employers, educational institutions and to otherwise verify the accuracy of the
information contained in this application. I hereby release from liability the employer and
its representatives for seeking, gathering and using such information and all other
persons, corporations or organizations for furnishing such information.
The employer does not unlawfully discriminate in employment and no question on this
application is used for the purpose of limiting or excusing any applicant from
consideration for employment on a basis prohibited by local, state or federal law.
This application is current for only 60 days. At the conclusion of this time, if I have not
heard from the employer and still wish to be considered for employment, it will be
necessary to fill out a new application.
I understand it is this company’s policy no to refuse to hire a qualified individual with a
disability because of that person’s need for a reasonable accommodation as required by
the ADA.
I also understand that if I am hired, I will be required to provide proof of identity and
legal work authorization.
I represent and warrant that I have read and fully understand the foregoing and seek
employment under these conditions.
Signature of Applicant ____________________________________ Date ___/___/___
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