Employment Application

Your Name, first, last and middle initial

Street Address

Apartment Number

City, State, Zip

Telephone number(s) where we can contact you:

Home

Work

Cell

Email (required)

How do you prefer we contact you:

Best time to contact you:

Are you 18 years of age or older?
YesNo

For Police Officer Applicants Only: Are you 21 years of age or older?
YesNo

Are you legally eligible to work in the United States and able to provide required documentation upon employment?
YesNo

(Failure to provide required documentation can result in dismissal.)

Have you ever been convicted of, or pled guilty or "Nolo Contendere" to a felony or misdemeanor?*
YesNo

Offense 1:

Date

Offense

Sentence and Location

Offense 2:

Date

Offense

Sentence and Location

Offense 3:

Date

Offense

Sentence and Location

Offense 4:

Date

Offense

Sentence and Location

*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.

EMPLOYMENT DESIRED

Job/Position

Date You Can Start

Minimum Salary Requested

Are you employed now?
YesNo

If "yes", may we contact your present employer for reference?
YesNo

Are you willing to work a rotating shift?
YesNo

Have you ever applied for a job with the City of Excelsior Springs before?
YesNo

Have you ever been employed by the City of Excelsior Springs before?
YesNo

If "yes", in what capacity, and why did you leave?

Are you related to any employee or elected official of the City of Excelsior Springs?
YesNo

If "yes", give name(s) and relationship(s).

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: