City Clerk Application

CITY OF MELCHER-DALLAS
EMPLOYMENT APPLICATION

This City is an equal opportunity employer and does not discriminate against any employee or applicant for employment on the basis of age, race, religion, creed, color, sex, national origin or disability.

Position Applied For Date of Application
Please answer ALL questions (you may add additional pages if necessary to fully respond to any question). Print or write carefully. If you provide false, inaccurate, or incomplete information in this application form or in any interview or if you fail to disclose information requested in this application form or in any interview, you will not be eligible for employment, or, if you are hired, you will be subject to termination.

PERSONAL INFORMATION
(To Be Completed By All Applicants)

__________________________________________________________________________________
Last Name First Name Middle Name

__________________________________________________________________________________
Street Address City State Zip Code Telephone

__________________________________________________________________________________
Are you 18 or older Social Security Number Are you legally eligible to work in the U.S.

__________________________________________________________________________________
e-mail address
Is there any name, other than the name stated above, which you have previously used to identify yourself:___________________________________________________________________________

If you are a military veteran, please provide information regarding your military service and type of discharge: _________________________________________________________________________ ____________________________________________________________

EMPLOYMENT HISTORY
(To Be Completed By All Applicants – List Most Recent Employer First)
**Be sure to include an explanation for all gaps in time of employment**

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Employer Name:__________________________________ Phone Number: ____________________

Start Date:_______________ End Date: ______________ Supervisor’s Name:__________________

Position held and duties: ______________________________________________________________

Employer’s address: _________________________________________________________________

Ending Salary: ____________________ Reason for Leaving: _________________________________

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Employer Name:__________________________________ Phone Number: ____________________

Start Date:________________ End Date: ______________ Supervisor’s Name:__________________

Position held and duties: ______________________________________________________________

Employer’s address: _________________________________________________________________

Ending Salary: ____________________ Reason for Leaving: _________________________________

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Employer Name:___________________________________ Phone Number: ____________________

Start Date:________________ End Date: ______________ Supervisor’s Name:__________________

Position held and duties: ______________________________________________________________

Employer’s address: _________________________________________________________________

Ending Salary: ____________________ Reason for Leaving: _________________________________

—————————————————————————————————————————-
Employer Name:___________________________________ Phone Number: ____________________

Start Date:________________ End Date: ______________ Supervisor’s Name:__________________

Position held and duties: ______________________________________________________________

Employer’s address: _________________________________________________________________

Ending Salary: ____________________ Reason for Leaving: _________________________________
Have you previously applied for employment with the City: ___________________ If “yes”, when and under what name: ________________________________________________________________

Have you previously been employed by the City: ____________ If “yes”, when and under what name:
__________________________________________________________________________________
EDUCATION
(To Be Completed By All Applicants)

High School Name ____________________________ Location (City/State) ____________________

Years Completed Diploma/Degree ________________________________

Colleges and Trade Schools
Name of School Location Years Completed Total Hours Degree Earned
__________ ____
__________________________________________________________________________________
__________________________________________________________________________________

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status:_____________________________________________________________________________
___________________________________________________________________________________

Describe any specialized training, apprenticeship, skills and extra-curricular activities. ____________
__________________________________________________________________________________
__________________________________________________________________________________

Other Qualifications. Summarize special job-related skills and qualifications acquired from employment or other experience. _______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Specialized Skills (Check Skills/Equipment Operated)

_____Word Other (list)
____ Excel _____ 10-Key __________________________________
____ Computer __________________________________
____ Fax _____Scan
____Copy Machine
State any additional information you feel may be helpful to us in considering your application.
__________________________________________________________________
CRIMINAL RECORD
(To Be Completed By All Applicants)

The term “convicted” includes a guilty plea, a plea of nolo contendere or no contest, a deferred judgment or adjudication, and an adjudication of guilt or delinquency as a minor.

If you answer “yes” to any of the following questions, you must provide detail on the back:

Have you ever been convicted of a felony: ________________________________________________
Have you ever been convicted of a serious misdemeanor: ____________________________________

Note: Convictions will not necessarily bar you from employment.
Professional References
Name:______________________________ Relationship:___________________________

How many years acquainted?____________ Address:_______________________________

Phone number:_______________________

Name:______________________________ Relationship:___________________________

How many years acquainted?____________ Address:_______________________________

Phone number:_______________________

Name:______________________________ Relationship:___________________________

How many years acquainted?____________ Address:_______________________________

Phone number:_______________________
FOR ALL APPLICANTS – PLEASE READ CAREFULLY BEFORE SIGNING

I hereby certify that the statements made by me in this application and all related information which I have provided are true, accurate and complete to the best of my knowledge. I understand that if I provide any false, inaccurate, or incomplete information, I will not be eligible for employment, or, if I am hired, regardless of the date on which the City discovers the violation of its policy regarding application form dishonesty, I understand I would be subject to immediate termination.

In connection with my application for employment with the City, I expressly authorize the release to the City of any records or information which may refer or relate to my application for employment, including, but not limited to, records of schools, law enforcement or criminal justice agencies, and previous employers. I hereby release and discharge the City and any other person, firm, agency or corporation from any and all claims and liability which I may have or ever claim to have relating to information provided to the City as part of my application for employment.

If I am offered and accept employment with the City, I understand that my employment is AT WILL and that my employment may be terminated at any time and for any reason either by me or by the City.
Signature ___________________________________ Date ____________