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Application for Employment

2. Position(s) Applied For

3. Application Date
   Application Date

5. How did you learn about us?*

   1. Newspaper
   2. Employment Agency
   3. Website

   1. Facebook
   2. Relative
   3. Friend

   1. Inquiry
   2. Other: __________________________________

7. Last Name*

8. First Name*

9. Middle Initial*

11. Address1*

13. Address2

15. City*

16. State*

17. Zip*

19. Telephone Number(s)*

20. E-Mail Address

24. GENERAL INFORMATION

26. Do you have a valid driver's license?*

    1. Yes

    1. No

27. If you are under 18 years of age, can you provide required proof of your elegibility to work?*

    1. Yes

    1. No

29. Have you filed an application with us before?*

    1. Yes

    1. No

30. Can you travel if the job requires it?*

    1. Yes

    1. No

32. Have you been employed with us before?*

    1. Yes

    1. No

33. Are any family or friends currently employed with us?*

    1. Yes

    1. No

35. If yes,

36. If yes,

38. Are you currently employed?*

    1. Yes

    1. No

39. May we contact your present employer?*

    1. Yes

    1. No

41. Are you a veteran of the U.S. Military Service?*

    1. Yes

    1. No

42. Are you currently on "lay-off" status and subject to recall?*

    1. Yes

    1. No

44. If yes,

46. Are you prevented from lawfully becoming employed in this country due to Visa or Immigration Status? *

    1. Yes

    1. No

    NOTE: Proof of citizenship or immigration status will be required upon employment.

50. Date available for work:
    Date available for work:

51. What is your desired salary range?*

52. Are you available to work:

    1. Full-Time
    2. Part-Time
    3. Temporary
56. EDUCATION & TRAINING

58. 1. High School: Name and Address.

59. Years Completed

61. Do you possess a high school deploma or GED?

    1. Yes

    1. No

63. 2. Undergraduate College: Name and Address.

64. Course of Study

66. Degree Earned?

    1. Yes

    1. No

67. Diploma / Degree

69. 3. Graduate Professional: Name and Address.

70. Course of Study

72. Degree Earned?

    1. Yes

    1. No

73. Diploma / Degree

75. 4. Other (Specify)

76. Course of Study

78. Degree Earned?

    1. Yes

    1. No

79. Diploma / Degree

81. Describe any specialized training, apprenticeship, skill and extra-curricular activities.

83. Describe any job-related training received in the United States military.

87. EMPLOYMENT EXPERIENCE:
    Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which may indicate race, color, religion, gender, national origin, disabilities or other protected status.

    Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which may indicate race, color, religion, gender, national origin, disabilities or other protected status.

89. 1. Employer

90. Address

91. Telephone

93. Job Title

94. Dates Employed

95. Hourly Rate / Salary

97. Supervisor

98. Reason for Leaving

100. Work Performed:

102. 2. Employer

103. Address

104. Telephone

106. Job Title

107. Dates Employed

108. Hourly Rate / Salary

110. Supervisor

111. Reason for Leaving

113. Work Performed:

115. 3. Employer

116. Address

117. Telephone

119. Job Title

120. Dates Employed

121. Hourly Rate / Salary

123. Supervisor

124. Reason for Leaving

126. Work Performed:

128. 4. Employer

129. Address

130. Telephone

132. Job Title

133. Dates Employed

134. Hourly Rate / Salary

136. Supervisor

137. Reason for Leaving

139. Work Performed

143. ADDITIONAL INFORMATION
     You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

     You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

145. List professional, trade, business or civic activities and offices held.

147. Other qualifications; Summarize special job-related skills and qualifications acquired from employment or other experience including software, machines, equipment, etc.:

151. REFERENCES:
     Give name, address, daytime telephone number of three references who are not related to you and are not previous employers.

     Give name, address, daytime telephone number of three references who are not related to you and are not previous employers.

153. 1.*

     Name, Address, Telephone & Email Address

155. 2.*

     Name, Address, Telephone & Email Address

157. 3.*

     Name, Address, Telephone & Email Address

161. DRUG - FREE WORKPLACE ACT COMPLIANCE:
     The City of Fairfield complies with the Drug-Free Workplace Act. As a condition of our employment, you may be asked to participate in drug screening. If you refuse such screening or test positive (evidence of drug use) you will not be offered employment or such offer will be withdrawn.

     The City of Fairfield complies with the Drug-Free Workplace Act. As a condition of our employment, you may be asked to participate in drug screening. If you refuse such screening or test positive (evidence of drug use) you will not be offered employment or such offer will be withdrawn.

163. AMERICAN WITH DISABILITIES ACT COMPLIANCE:
     The City of Fairfield fully subscribes to the provisions of the American with Disabilities Act and will attempt in its employment process to make any reasonable accommodations necessary to assist qualified person with disabilities.

     The City of Fairfield fully subscribes to the provisions of the American with Disabilities Act and will attempt in its employment process to make any reasonable accommodations necessary to assist qualified person with disabilities.

165. "EQUAL OPPORTUNITY EMPLOYER"

167. I understand that nothing in this application is intended to imply or create an employment relationship or contract for employment. I further understand that, if hired, my employment is at-will and can be terminated at any time, with or without notice, for any reason. I also understand that while personnel policies, programs, and procedures may of necessity change from time to time, such at-will status is not subject to change absent a written agreement signed by an authorized representative of the City of Fairfield.

169. Applicant Name*

     By inserting your name, you agree to the above statement.

170. Date*
     Date

172. Cover Letter / Resume

     Attach cover letter and/or resume here.

Leave This Blank:


173. 1. Receive an email copy of this form.
174. Email address

     This field is not part of the form submission.

175. Submit Submit and Print

* indicates a required field