Are you legally eligible to work in the United States and able to provide required documentation upon employment?
Yes No
Have you ever been convicted of, or pled guilty or "Nolo Contendere" to a felony or misdemeanor?*
Yes No
*Conviction will not automatically disqualify you from employment consideration. We will consider the nature of the offense in relation to the job for which you are applying.
Are you related to any employee or elected official of the City of Excelsior Springs?
Yes No
EDUCATION
High School:
Name and Location of School
Course of Study
Number of Years Completed
Diploma, Certificate or Degree Received
College or University:
Name and Location of School
Course of Study
Number of Years Completed
Diploma, Certificate or Degree Received
Vocational or Trade School:
Name and Location of School
Course of Study
Number of Years Completed
Diploma, Certificate or Degree Received
Graduate School:
Name and Location of School
Course of Study
Number of Years Completed
Diploma, Certificate or Degree Received
WORK HISTORY
(Start with your present or most recent employment and provide ALL information requested, even if a resume is attached.)
Name of Employer
Complete address, including street, city, state and zip code
Dates employed, from month/year to month/day/year
Telephone number, starting with area code
Supervisor's name and title
Starting Salary
Ending Salary
Give title(s) of position(s) held and describe the duties and responsibilities of each.
Reason for leaving
Name of Employer
Complete address, including street, city, state and zip code
Dates employed, from month/year to month/day/year
Telephone number, starting with area code
Supervisor's name and title
Starting Salary
Ending Salary
Give title(s) of position(s) held and describe the duties and responsibilities of each.
Reason for leaving
List any special certifications, courses, training or skills that would be of benefit in the job for which you are applying.
REFERENCES
(List the names of three persons who you have known at least one year. Do not include family members.)
Name
Job
Phone Number
City, State
Years Known
Name
Job
Phone Number
City, State
Years Known
Name
Job
Phone Number
City, State
Years Known
Name
Job
Phone Number
City, State
Years Known
I certify that the statements contained in the application are true and complete to the best of my knowledge. I understand that, if hired, false or misleading information given in my application, resume or interview(s) may result in immediate dismissal.
I authorize the City of Excelsior Springs to verify all statements contained in the application for employment and to make reference and background checks as its representatives deem necessary. You are hereby authorized to make any investigation of my personal character, academic records or employment history, and I release all parties from any claim arising in connection with their giving the same to you.
In understand and agree that I may be required to take one or more physical examinations, including drug and alcohol screens, as a condition of hiring or continued employment. I agree to consent to take such examination(s) at such time as designated by the City of Excelsior Springs.
I further understand that if I am employed, I will be at "at will" employee, free to resign without notice or to be dismissed without notice.
Date
Applicant Signature
Attachment:
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