Executive Officer Chief

THE CLARKSVILLE HOUSING AUTHORITY EMPLOYMENT APPLICATION

FOR OFFICE USE ONLY

Work

Location

Position

Rate

Date

(An Equal Opportunity Employer)

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. We will give this application every consideration. However, in accepting it, the Company makes no commitment of employment to the applicant. This application will remain active for six months.

WE ARE AN AT-WILL EMPLOYER, MEANING THAT EITHER THE EMPLOYER OR THE EMPLOYEE MAY END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON. BASIC INFORMATION: Please print in ink.

Position Applied For:

Date of Application:

How Did You Learn About Us?

ο Advertisement ο Friend ο Walk-In

ο Employment Agency ο Relative ο Other Last Name First Name Middle Name

Address City State Zip Code

Telephone Number(s) Social Security Number

ADDITIONAL INFORMATION

Salary requirements: Date Available: Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony within the last 7 years? Yes No

If yes, please explain:

Have you ever been employed by this agency in the past? Yes No If so, what position? Dates? Reason you left? I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.? Yes No

Do you need a reasonable accommodation to fulfill the position applied for? Yes No MILITARY HISTORY:

Have you even been in the Armed Forces? Yes No Date entered Date Discharged?

Are you now a member of the National Guard? Yes No Specialty EMPLOYMENT HISTORY: Start with your present or most recent job. Include any job-related military service assignments, self-employment, summer and part-time jobs. 1

Company Address Telephone

Dates From To

Employed

Salary

Starting Leaving

Supervisor

Your Duties:

Reason for Leaving:

2 Company Address Telephone

Dates From To

Employed

Salary

Starting Leaving

Supervisor

Your Duties:

Reason for Leaving:

3 Company Address Telephone

Dates From To

Employed

Salary

Starting Leaving

Supervisor

Your Duties:

Reason for Leaving:

4 Company Address Telephone

Date From To

Employed

Salary

Starting Leaving

Supervisor

Your Duties:

Reason for Leaving:

If presently employed, why do you desire to change your position? If you are now employed, may we contact your present employer? Yes No REFERENCES: (not former employers or relatives)

Name

Address Phone Number

EDUCATION:

School Name and

Address

of School

Course of

Study

Circle Last

Year

Completed

Did You

Graduate?

List

Diploma

or Degree

High 1 2 3 4 ο Yes

ο No

College

1 2 3 4 ο Yes

ο No

Other

(Specify)

1 2 3 4 ο Yes

ο No

If you did not graduate, why did you leave school or college? Are you planning to pursue further studies? ο Yes ο No If yes, ο Day or ο Night School

If so, when, where, and what courses? INTERESTS: Use this space below to describe interest in the industry and job-related skills and aptitudes that you feel qualify you for a position with our Company. If you need more space, please continue on a separate sheet.

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*

ACKNOWLEDGEMENT

Please Read Before Signing:

The facts set forth in my application for employment are true and complete. I understand that if employed, false or misleading statements on this application shall be considered immediate cause for dismissal. In making this application for employment I authorize you to make and/or investigate a report whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation, personal characteristics, and mode of living. This inquiry, if made, also may include information concerning any and all employment discrimination claims and/or accusations brought against me, including, but not limited to, charges and/or accusations brought against me that relate to harassment and/or discrimination involving race, sex, age, religion, disability, and/or national origin. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any such investigation or report that is made. I understand that any employment offer is contingent upon my undergoing a drug and alcohol test. I UNDERSTAND THAT, IF THE COMPANY EMPLOYS ME, EITHER THE COMPANY OR I CAN TERMINATE MY EMPLOYMENT WITH OR WITHOUT CAUSE AT ANY TIME AND FOR ANY OR NO REASON. I also understand that no official of the Company other than the Chief Executive Officer has any authority to enter into an agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

Signature of Applicant Date

ADDENDUM TO THE CLARKSVILLE HOUSING AUTHORITY

APPLICATION

I hereby represent that all information furnished to The Clarksville Housing Authority is true and correct. I further represent that such information constitutes a full and complete disclosure of my knowledge of the information. I understand that any incorrect, incomplete, or false statement of information furnished by me will subject me to discharge at any time. In the event that I am employed by The Clarksville Housing Authority, I agree to comply with all of The Authority’s orders, rules and regulations. Applicants offered employment with The Clarksville Housing Authority will be required to undergo a conditional employment assessment to determine their ability to perform the essential elements of the position.

It is also understood and agreed upon, that as a condition of employment with The Clarksville Housing Authority, that I may be required to consent to an alcohol and/or drug screening. Refusal to consent to such a screening will result in denial of employment with The Clarksville Housing Authority. A final employment offer or position appointment (aside from any pre-employment offer and/or temporary job assignment) will be contingent on your satisfactory completion of an ability assessment (physical), and background investigation, or any other employment screening evaluations deemed appropriate by the hiring department. Acknowledgement of Understanding

Name Date Applicant Signature

THE CLARKSVILLE HOUSING AUTHORITY

JOB APPLICANT REQUIREMENTS

I hereby consent to submit to urinalysis and or other tests as shall be determined by The Clarksville Housing Authority in the selection process of applicants for employment, for the purpose of determining the drug content thereof. I agree that a physician of The Clarksville Housing Authority’s choosing may collect these specimens for these tests. I further agree to and hereby authorize the release of the results of said tests to The Clarksville Housing Authority. I have been provided with a list of drugs to be tested for.,

I understand that it is the current illegal use of drugs and or abuse of alcohol that will prohibit me from being employed at the Clarksville Housing Authority. It is also understood that I may be required to provide a letter from my physician showing that I am able to perform the job tasks as identified on the job description provided to me. A final employment offer or position appointment will be contingent upon my completion and submission of the drug screening and physical evaluation ( if requested) to The Clarksville Housing Authority.

Refusal to consent to such evaluations will result in denial of employment with The Clarksville Housing Authority.

Applicant Signature:

Date:

The Clarksville Housing Authority requires substance abuse testing for job applicants. Testing for the following drugs or alcohol may be performed:

• Breath Alcohol Testing

• EtG/EtS Alcohol Test

• Blood Alcohol Test

• Marijuana, Cocaine, Amphetamine & Methamphetamine, Phencyclidine (PCP), Benzodiazepines, Barbiturates, Methadone, Methaqualone, Propoxyphene, Opiates including codeine, morphine, 6- acetyl morphine ( heroin specific metabolite), Hydrocodone, Hydromorphone, Oxycodone and Oxymorphone

• Tramadol

• Meperidine

• Buprenorphine, Suboxone

• Fentanyl

• Ketamine

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