Melcher-Dallas Employment 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: _________________________________________________________________

—————————————————————————————————————————-

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____________