Form Center

Step One

Name (As it appears on Social Security Card / Work Permit Card)*
Last, First, Middle Initial
Address*
City
State
Zip Code
Home Phone Number*
Daytime Phone Number
Are you at least 18 years old?*
1. Yes
2. No
Other Names You Have Used
Position Applied For*
Salary Requirements
Referred for This Position By
Date Available
Date Available
Have you ever been employed by this organization?
1. Yes
2. No
If yes, when and by which department?
Supervisor
Reason for Leaving
Have you ever been convicted of a felony?
1. Yes
2. No
A conviction will not necessarily disqualify an applicant from employment. The applicant is not obligated to disclose sealed or expunged records of conviction.
If yes, give location, date, charge and disposition of case(s) on a separate page
I have a valid driver's license.
1. Yes
2. No
Can you, if hired, submit verification of your legal right to work in the United States?
1. Yes
2. No
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U.S. Military Service

If you have served in the U.S. Military, please provide the following information:
Branch of Service
Dates Served
Dates Served Start Date
—
Dates Served End Date
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Education / Skills

High School Name*
Address
City
State
Zip Code
Check all years completed:
1. 9
2. 10
3. 11
4. 12
Units Completed
Degree
Major
Check all that have been completed.
1. Community/Junior College
2. Business/Trade School
3. College or University
4. Graduate School
Submit name and address of school, number of years completed, units completed, major, and degree earned.
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Computer Software Skills

Licenses / Certifications / Organizations

Professional Licenses and Certifications
Include the type, registration number, state, and the month and year of expiration.
Professional, Scholastic, and Other Organizations (Job Related)
Exclude memberships that indicate your race, religion, color, national origin, ancestry, sex, age, disability, or veteran status.
Job Related Training
List the name of any courses you have taken related to this position.
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Employment History

This portion of the application must include a minimum of a 10 year work history.
List your most recent employer first including U.S. Military Service and unpaid or volunteer work. Base Salary does not include overtime, bonuses, or commissions.
When were you employed here?
When were you employed here? Start Date
—
When were you employed here? End Date
Position
Supervisor
Employer
Street Address
City
State
Zip Code
Phone Number
Type of Business
Reason for Leaving
Provide a brief description of your duties and responsibilities.
When were you employed here?
When were you employed here? Start Date
—
When were you employed here? End Date
Position
Supervisor
Employer
Street Address
City
State
Zip Code
Phone Number
Type of Business
Reason for Leaving
Provide a brief description of your duties and responsibilities.
When were you employed here?
When were you employed here? Start Date
—
When were you employed here? End Date
Position
Supervisor
Employer
Street Address
City
State
Zip Code
Phone Number
Type of Business
Reason for Leaving
Provide a brief description of your duties and responsibilities.
When were you employed here?
When were you employed here? Start Date
—
When were you employed here? End Date
Position
Supervisor
Employer
Street Address
City
State
Zip Code
Phone Number
Type of Business
Reason for Leaving
Provide a brief description of your duties and responsibilities.
When were you employed here?
When were you employed here? Start Date
—
When were you employed here? End Date
Position
Supervisor
Employer
Street Address
City
State
Zip Code
Phone Number
Type of Business
Reason for Leaving
Provide a brief description of your duties and responsibilities.
Explanation of Interruptions in Employment History
Please use this space to explain employment history interruptions since high school that do not pertain to pregnancy, child care, disability or any other protected activity.
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References & Emergency Contact

Name
Address
City
State
Zip Code
Daytime Phone Number
Relationship
No relatives
Name
Address
City
State
Zip Code
Daytime Phone Number
Relationship
No relatives
Name
Address
City
State
Zip Code
Daytime Phone Number
Relationship
No relatives
Name
Address
City
State
Zip Code
Daytime Phone Number
Relationship
No relatives
Emergency Contact
Name
Address
City
State
Zip Code
Home Phone Number
Business Phone Number
Relationship
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Authorization & Agreement

I hereby authorize you to contact my present employer.*
1. Yes
2. No
I hereby authorize you to contact my past employers.*
1. Yes
2. No
As part of our normal procedure in processing applications, a routine inquiry will be made concerning your background. Former employers, school record offices and personal, school and employment references may be contacted to verify and obtain information concerning your background, qualifications, school and work records. You may be asked to sign another form authorizing the release of school records or to supply grade transcripts. Information gathered about your background and qualifications will be used to help make a fair employment decision. This information will only be available to those participating in this decision or those who process employment applications. As part of this investigation, a check of criminal records will also be conducted. This agency may keep and use information it supplies to us in this investigation for its own business purposes. Further information such as the name of the consumer reporting agency or the nature and scope of such inquiry, if one is made, is available to you upon written request. You will also be given a separate disclosure and authorization to review and sign concerning any reports prepared about your background for us by a consumer reporting agency that compiled the report.
I hereby authorize the employer, its representatives, employees or agents to conduct all pre-employment inquiries and tests as described. I further authorize the employer and its agents to verify all statements contained in this application and any other materials I submitin connection with my employment application. I agree to complete any requisite authorizations forms. I release the employer, its agents and all providers of information from any liability arising out of the gathering and use of such information. In the event of employment, this authorization and release isvalid throughout my employment and a photocopy is as effective as the original.
I understand all offers of employment are conditional upon satisfactory reference checks, successful completion of all pre-employment tests and production of all documents necessary for the employer to verify my identity and work authorization in accordance with the requirements of the Immigration and Naturalization Services.
As an employer, this organization is subject to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Applicants who believe they are covered by these Acts are invited to identify their disabilities and special accommodations they feel are necessary to adequately perform their jobs. Submission of this information is strictly voluntary and may be made to the Human Resources Manager.
I certify the information provided in this application is true and complete to the best of my knowledge. I understand withholding pertinent information or submitting false or misleading information on this application, my resume, during interviews or at any other time during the hiring process constitutes valid grounds for disqualification from further consideration for hire or immediate dismissal from employment and loss of all employee benefits and privileges. I further understand and agree that the employer shall not be liable in any respect if my employment is so denied or terminated.
I understand and agree that if I am applying for a law enforcement or jail position, I will be required to comply with all the requirements of the Peace Officer Standards and Training Board (or equivalent agency) required by the state. I further understand that any offer of employment is conditioned upon completing all those tests, including physical agility, to determine my fitness for this position.
I understand the acceptance of this application by the employer neither expresses nor implies I will be offered employment. I understand my employment is at will and I may resign at any time forany reason; similarly, my employment may be terminated by the organization at any time for any reason. Any changes to this at-will employment agreement will not be valid unless in writing signed by me and a duly authorized representative of this employing organization.
I have read the above authorization and agreement statements.*
1. Yes
2. No
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Fair Credit Reporting Act

Disclosure and Authorization Statement
To: All Applicants For Employment (Please Read Carefully)
In processing my application for employment, I understand the employer, its representatives, employees or agents may obtain a consumer report and investigative consumer report for employment purposes concerning my past employment, work habits, education, military record, motor vehicle record, credit background, references, character, general reputation, personal characteristics, mode of living, civil judgments, liens, and information about my criminal conviction background consistent with state and federal law.
I understand an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics or mode of living is obtained through personal interviews with neighbors, friends, associates or others with whom I am acquainted or who may have knowledge concerning this information.
By signing below, I authorize this employer to obtain a consumer report and an investigative consumer report on me as part of the preemployment background and investigation process. If I am offered employment, I further authorize my employer to obtain additional consumer and investigative consumer reports and updates on me for employment purposes at any time during my employment. A copy of this authorization is as valid as the original.
I have read and agree to the above statement.*
1. Yes
2. No
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Employment Application for Police & Fire Departments

Steps

Step One

U.S. Military Service

Education / Skills

Computer Software Skills

Licenses / Certifications / Organizations

Employment History

References & Emergency Contact

Authorization & Agreement

Fair Credit Reporting Act

Police & Fire Department Application Supplement

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