Are you available to work: Full Time Part Time Shift Work Temporary

Are you currently on “lay-off” status and subject to recall Yes No Can you travel if the job requires it Have you been convicted of a felony within the last seven (7) years? (Conviction will not necessarily Yes No

disqualify you from employment) If yes, please explain:

Yes No

Are you related to, married to, or planning on marrying any Town employee or anyone on Town Council, Board, Commission? If yes, who

If so, whom?

Yes No

Town of Dewey-Humboldt

2735 S. Hwy 69

PO Box 69

Humboldt, AZ 86329

Phone: 928-***-****

Fax: 928-***-****

www.dhaz.gov

Application for Employment

We consider applicants for all positions without regard to race, creed, color, sex, age, disability, religion, veteran status, or national origin. Please complete a separate application for each job title. Applications will not be accepted unless a position has been posted. Applications are position specific.

(PLEASE PRINT)

Position Applied For Date of Application

How Did You Learn About Us? Advertisement Employment Agency Website Friend Relative Walk-In Other Last Name First Name Middle Name

Address Apt. City State Zip

Telephone Number(s) Valid Arizona Driver’s License Number Acceptable salary (Please refer to the posted hiring salary range for the position you are applying for) Current Employee of Town Dewey-Humboldt Government Yes No If you are under eighteen (18) years of age, can you provide proof of your eligibility to work? Yes No Have you ever filed an application with us before? If Yes, give date Have you ever been employed with us before? If Yes, give date Yes No

Yes No

Are you currently employed Yes No May we contact your present employer prior to any job offer Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

(Proof of citizenship or immigration status will be required upon employment) Yes No On what date would you be available for work EDUCATION

Name and Address of School

Course of Study

Years

Completed

Diploma

Degree

Junior High

School

High School

Undergraduate

College

Graduate

Professional

Other

(Specify)

(All college or university work claimed for meeting job requirements must be supported by official or unofficial transcripts, or a copy of the degree.)

EDUCATION (continued)

Indicate Any Foreign Languages You Can Speak, Read and/or Write FLUENT GOOD FAIR

SPEAK

READ

WRITE

Describe any specialized training, apprenticeship skills, and/or professional certificates. Describe any job-related training received in the United States military. EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military assignments and volunteer activities. You may exclude organizations, if you wish, that indicate any protected status such as race, creed, color, sex, age, disability, religion, veteran status, or national origin. Please describe clearly the tasks performed or responsibilities as they relate to the job for which you are applying.

1.

Employer Dates Employed Work Performed

From To

Address

Telephone Number(s) Hourly Rate/Salary

Starting Final

Job Title Supervisor

Reason For Leaving # Of Hours Per Week

2.

Employer Dates Employed Work Performed

From To

Address

Telephone Number(s) Hourly Rate/Salary

Starting Final

Job Title Supervisor

Reason For Leaving # Of Hours Per Week

EMPLOYMENT EXPERIENCE (continued)

3.

Employer Dates Employed Work Performed

From To

Address

Telephone Number(s) Hourly Rate/Salary

Starting Final

Job Title Supervisor

Reason For Leaving # Of Hours Per Week

4.

Employer Dates Employed Work Performed

From To

Address

Telephone Number(s) Hourly Rate/Salary

Starting Final

Job Title Supervisor

Reason For Leaving # Of Hours Per Week

If you need additional space, please continue on a separate sheet of paper. ADDITIONAL INFORMATION

References:

Name Name Name

Address Address Address

City State City State City State

Phone Number(s) Phone Number(s) Phone Number(s

Specialized Skills – Check Skills

Calculator Computer

E-mail Fax

Internet Spreadsheet

Word Processing

Other

List Any Equipment Operated

Driver’s License Number if essential function of

the job.

State Type

State any additional information you feel may be helpful to us in considering your application. APPLICANT’S SIGNATURE

Signature Required (read before signing)

By signing this application for employment, I certify that I have truthfully and completely answered all questions. I understand that falsification of any of the information given herein, on any other employment form, or during the interview is grounds for immediate termination, regardless of when such falsification may be discovered. I expressly authorize, without reservation, Town of Dewey-Humboldt, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

Further, I understand that employment will be contingent upon successfully passing a post offer, pre- qualification drug screening test or other required test for safety-sensitive positions. I understand that my employment with the Town of Dewey-Humboldt is “at-will” and there are no contractual rights. I understand that there will be a probation period during which time an evaluation will be made as to my performance and suitability for the position; I further understand that the probation period does not alter the “at-will” status of my employment. I understand that no employee or representative of Town of Dewey-Humboldt has any authority to make any agreement that is contrary to the foregoing statements. If accepted for employment, I agree to comply with all of Town’s policies, procedures, and with all rules and regulations made known to me at the time of employment or any other time thereafter, and to perform all duties assigned to me that are required by my supervisor. I understand that all applications are job specific. Another application must be filled out and submitted for any other positions or openings posted by the Town of Dewey-Humboldt.

I certify that I have read, fully understand and accept all terms of the foregoing statement. Signature of Applicant Date

FOR INTERNAL USE ONLY

Arrange Interview Yes No

Accept

Remarks Reject By Date

Employed Yes No Date of Employment

Interviewer Date

Job Title Hourly Rate/Salary Department

Town Manager signature: _ Date:

Revised: May 2015

Contact this candidate