Limpieza Human Resources

City of Powder Springs

Application for Employment

Human Resources

P.O. Box 46

Powder Springs, GA 30127

Phone: 770-***-****

The City of Powder Springs is an Equal Opportunity and EEO/Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, national or ethnic origin, disability, age, veteran status, or sexual orientation. Information provided on this application is subject to the Georgia Open Records Act (O.C.G.A. §50-18-70). PLEASE TYPE OR PRINT. Complete both sides of the application. You may attach a resume, but you must still complete all questions; or your application will be deemed incomplete and may not be considered. Please fill out each box (don't just indicate “See Resume.”) Applications with missing or invalid job titles will not be considered for any position. Name (Last, First, Middle) Other names under which you have attended school or been employed:

Street Address City, State & ZIP

Must Indicate Position Applying For: Home Phone Work Phone Other Phone Are you eligible to work in the United States? Yes No Are you 18 years of age or older? Yes No If NO, what is your current age? Are you currently employed at the City? Yes No If YES, what is your current job title & department? Have you ever been employed by the City of

Powder Springs

Yes No If YES, dates of employment & reason for leaving: Are you related to any current City employee? Yes No If YES, their name & their relationship to you? If required for position, do you have a valid

driver’s license?

Yes No If YES, State of issuance, license #, and expiration date: How did you learn about this employment opportunity at City of Powder Springs? Check all that apply:

Job Bulletin (Posting) /Walk-in Website GA Dept. of Labor Ad in newspaper Referral by a City employee

Job Posting at (please specify where you saw the job posting:

Other:

EDUCATION

Name of School

City/State

Did you

graduate?

If No, # of years

left to graduate

If Yes, date of

Graduation

Degree

received

Major

High School

Yes No

GED

Yes No

Other School

e.g.,Vocational

Yes No

College/University

Yes No

College/University

Yes No

College/University

Yes No

Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying. SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert) OVER

For Human Resources Use Only:

ELIGIBILITY: Yes No Checked by: Date:

WORK EXPERIENCE-Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation “See Resume.” PLEASE NOTE: The City of Powder Springs reserves the right to contact all current and former employers for reference information. Dates Employed (most recent position)

From:

/ to /

mo yr mo yr

Full time Part-time

If part-time, # hrs./wk:

Title:

Starting Salary:

Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone #:

Other Reference Name, Title and Phone #:

Contact my current references:

At any time

Only if I am a finalist candidate

Primary duties:

Reason for Leaving

Dates Employed

From:

/ to /

mo yr mo yr

Full time Part-time

If part-time, # hrs./wk:

Title:

Starting Salary: Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone #: Other Reference Name, Title and Phone # Contact these references:

At any time

Only if I am a finalist candidate

Primary duties:

Reason for Leaving:

Dates Employed

From:

/ to /

mo yr mo yr

Full time Part-time

If part-time, # hrs./wk:

Title:

Starting Salary: Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone

Number:

Other Reference Name, Title and Phone

Number:

Contact these references:

At any time

Only if I am a finalist candidate

Primary duties:

Reason for Leaving

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize the City of Powder Springs to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of the City serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States, and to comply with City and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first TWELVE MONTHS of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal. APPLICANT SIGNATURE DATE APP FORM 10/14/2009

Contact this candidate