CITY OF Overlooking Perry Lake PO- Box 120 • 524 Kiowa

^ ^ Ozawkie, KS 66070

APPLICATION FOR EMPLOYMENT "̂^̂^̂^̂^̂^̂ AN EQUAL OPPORTUNITY EMPLOYER

INSTRUCTIONS T O APPLICANT;

1. Please print clearly or type infomiation. 2. Fi l l out the entire application even though you may be including a resume. An incomplete or incorrect

application form may result in your application not being considered. 3. Applications are kept on file for six months.

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the Human Resources Department.

Date of this Application: Date available for work:

Position for which this Application is being submitted:

If you are applying for an instructor position, please specify the subject area(s) you wish to teach:

PERSONAL DATA

(1) Name: First Middle Ust Other Last Name

(2) Present Address:

(3) Day Phone #: (

(4) Email Address:

City/State/Zip

Evening Phone # ( )

(5) Driver's License Number & State i f driving is an essential job function:

(6) Are you legally eligible for employment in the United States? Yes

(7) Are you 18 years of age or older? Yes No I f you answered no, are you at least 16 years of age? yes

(8) Have you ever been employed with us Yes

(9) Have you ever been convicted of a felony? Yes

No

No

No I I I f yes, when? No •

I f yes, please explain (Conviction will not necessarily disqualify you from employment):

EDUCATIONAL DATA

NOTE: If necessary, continue on separate sheet.

HIGH SCHOOL:

School Name:

Did you graduate? Yes No

I f no, have you earned a GED Certificate?

Yes No 1 School Address:

Did you graduate? Yes No

I f no, have you earned a GED Certificate?

Yes No 1

Did you graduate? Yes No

I f no, have you earned a GED Certificate?

Yes No 1

Did you graduate? Yes No

I f no, have you earned a GED Certificate?

Yes No 1

C O L L E G E / U N I V E R S I T Y :

Institution Name:

Sem. t_J Credit Hours Completed: ^ p|

Did vou graduate? Yes No 1 1 I f yes, type of Degree Earned: Address:

Sem. t_J Credit Hours Completed: ^ p|

Did vou graduate? Yes No 1 1 I f yes, type of Degree Earned:

Area of Study:

C O L L E G E / U N I V E R S I T Y :

Institution Name:

Sem.n Credit Hours Completed: | |

Did you graduate? Yes No | |

I f yes, type of Degree Earned: Address:

Sem.n Credit Hours Completed: | |

Did you graduate? Yes No | |

I f yes, type of Degree Earned:

Area of Study:

C O L L E G E A J N I V E R S I T Y :

Institution Name:

Sem,n Credit Hours Completed: Q

Did you graduate? Yes No

I f yes, type of Degree Earned: Address:

Sem,n Credit Hours Completed: Q

Did you graduate? Yes No

I f yes, type of Degree Earned:

Area of Study:

BUSINESSA^RADE/TECHNICAL/OTHER:

Institution Name:

Address;

Credit Hours Completed:

Did you graduate? Yes

Sem.

Qtr.

No

I f yes, type of Degree Earned:

Area of Study:

E M P L O Y M E N T H I S T O R Y 1. Start with your present or most recent employer 2. Account for all the time periods. 3. Please give accurate, complete full-time and part-time

employment record for a minimum of five years past.

NO: FE: If necessary, continue on separate sheet.

1

Company Name Telephone ( )

1

Address Employed (State month and year)

From To

1 Name & Title of Supervisor

.Starting Rate of Pay: $ per

Ending Rate of Pay: $ per 1

State Job Title and Describe Your Work Reason for Leaving

1

2

Company Name Telephone ( )

2

Address Employed (State month and year)

From To

2 Name & Title of Supervisor

Starting Rate of Pay; $ per

Ending Rate of Pay: $ per 2 State Job Title and Describe Your Work- Reason for Leaving

2

Company Name Telephone ( )

Address Employed (Slate month and year)

From To

3 Name & TiUe of Starting Rate of Pay: $ per 3 Supervisor Ending Rate of Pay: $ per

State Job Title and Describe Your Woric Reason for Leaving

Company Name Telephone ( )

Addi'ess Employed (State month and year)

From To

A Name & Title of Starting Rate of Pay: $ per Super\'isor Ending Rate of Pay: $ per State Job Title and Describe Your Work Reason for Leaving

We may contact the employers listed above unless you indicate those you do not want us to contact.

Employer Number(s)

DO NOT CONTACT

Reason

M I S C E L L A N E O U S D A T A

List civic, technical, trade, professional or other organization memberships that are relevant to this position. (Exclude those which may disclose your race, color, religion, or national origin.)

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

What positions of leadership or responsibility have you held in school, work, or elsewhere?

Are there any duties of this position which you carmot perform or is there anything that will interfere with your ability to do this position? I f yes, please describe:

How did you learn about the job for which you are applying?

newspaper advertisement Q friend Q relative

employment agency

current employee

I I internet site

Other: Please describe:

APPLICANT STATEMENT

I certify that ail information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer 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.

I understand this application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

DO NOT SIGN UNTIL Y O U HAVE R E A D T H E A B O V E APPLICANT STATEMENT.

[ j I certify that I have read, fiiUy understand and accept all terms of the foregoing Applicant Statement.

Signature Date