APPLICATION FOR EMPLOYMENT

An Equal Opportunity/Affirmative Action Employer

If you need assistance in completing the employment application, please inquire at the personnel office. Furthermore, this employer conducts pre-employment qualification testing and personal interviews in the application process. If you believe you will require reasonable accommodation (e.g., interpreter, TDD, scheduling adjustments) for pre-employment testing or a personal interview, you must notify the personnel office at least 24 hours prior to the scheduled test or interview.

PERSONAL DATA

(Last Name) (First Name) (Initial)

(Street Address, RFD, or P.O. Box)

(City) (State) (Zip Code)

Phone Number: Social Security Number: Position(s) Applied For: When would you be available to start work? Check each type of work you will accept: θ Regular θ Temporary θ Part time θ Full time Have you filed an application here before? θ Yes θ No If yes, date: Have you ever been employed here before? θ Yes θ No If yes, date(s): Do you have any relatives employed by the city of Henderson? Yes No; If yes, state their name, position and how related? Are you or your spouse related to any officer or employee of this employer? θ Yes θ No Minimum Acceptable Salary: $ per (e.g., per week, month, year, etc.) EDUCATION AND TRAINING:

Name of Schools

Attended and Location

Dates

Attended

From To

Average

Grades

Major

Field

Degree

Received

SKILLS:

The following space is provided for other information concerning special training, interests, career goals, or any other data you wish to provide.

Computer: θ IBM-PC, wpm Software Proficiency: θ WordPerfect, Version θ Macintosh, wpm θ Word, Version

θ Other computer,

specify:

θ Other word processor,

specify:

Equipment: θ Standard Business Copier(s) θ Lotus 1-2-3, Version θ Calculator (by touch) θ Excel, Version

θ Photography Equipment

specify:

θ Other spreadsheet,

specify:

θ PBX or other Switchboard θ Database, specify: θ Other Equipment,

specify:

θ Desktop Publishing,

specify:

EMPLOYMENT EXPERIENCE:

List each position held. Start with your present or most recent assignment and work backward. If you need additional space, please continue on separate sheet(s) of paper. In the column at the right, describe your assignments. Attach additional sheets as necessary. Resume may be submitted to supplement this information, but the information below must be completed for this application to be considered. May inquiry be made of your present employer? θ Yes θ No Employer: Address: Dates: From To

Job Title: Summary of Job Duties: Supervisor:

Reason for Leaving: Starting Salary: Ending Salary: Employer: Address: Dates: From To

Job Title: Summary of Job Duties: Supervisor:

Reason for Leaving: Starting Salary: Ending Salary: Employer: Address: Dates: From To

Job Title: Summary of Job Duties: Supervisor:

Reason for Leaving: Starting Salary: Ending Salary: Employer: Address: Dates: From To

Job Title: Summary of Job Duties: Supervisor:

Reason for Leaving: Starting Salary: Ending Salary: ADDITIONAL INFORMATION:

By law, you must be authorized to work in the United States in order to be employed by this employer. If you are one of the following, please check this box: θ

• A citizen or a national of the United States.

• An alien lawfully admitted for permanent residence.

• An alien authorized by the Immigration and Naturalization Service to work indefinitely in the United States.

During the past seven years, have you been convicted of, or have you pled guilty or no contest to, a felony offense or a misdemeanor theft? θ Yes θ No

If yes, please explain on reverse side of page. (You may omit convictions for minor traffic violations unless the position for which you are applying requires the operation of a motor vehicle). Convictions will not result in your automatic disqualification for employment. The seriousness of the crime, the date of conviction, the function of the job, and the relevance of the crime to this position will be considered.) If the position for which you are applying requires operating a motor vehicle, do you have a valid Texas driver's license?

θ Yes θ No

If yes, type of license: θOperator θCommercial, Type θChauffeur REFERENCES:

List three persons not related to you who are qualified to describe your capabilities for the position you seek. Name Address Phone Occupation

I hereby authorize this employer to review and obtain my employment records from all of the employers listed above. I certify that the statements and information contained herein are true, complete, and correct to the best of my knowledge, and I authorize any former employer to release to this employer or its authorized representative any and all employment records and other information it may have about my employment. I understand that the information will be used for the purpose of evaluating my application for employment and that I am responsible for providing legal documents verifying my identity and eligibility for employment. In addition, I understand that, if selected for an interview, true copies of all degrees, certificates, or licenses listed on this application will be required before an employment decision can be made. A photocopy of this authorization shall be as valid as the original.

I understand and agree that any offer of employment will be contingent upon my satisfactorily passing a drug and alcohol test. Further, I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, and that intentional misrepresentation on my application or during the interview process will subject me to immediate discharge. I also understand that only written representations and promises of this employer will be enforceable. Signature of Applicant: Date:

Contact this candidate