CITY OF DICKSON

Please read these statements carefully before you complete this application: All statements made by applicants for employment on the application form will be carefully checked for accuracy. We offer equal employment opportunities to all persons without regard to race, religion, age, sex, national origin, disability, veteran or marital status. Interdepartmental transfers and promotions are selected based on applicant's job qualifications, quality of work, experience, general aptitude, licensure and support and compliance of policies and procedures outlined by each department and the city. The use of this form does not mean there are positions open and does not obligate us in any way. The application will remain on active file for a period of three (3) months from date of application and on active file for public safety employee positions for a period of one year from date of application.

With regard to my employment application, I understand that as a part of normal procedure for processing employment applications and employment requests, a routine inquiry may be made to ascertain information on character, general reputation, credit, personal characteristics, etc. I understand that the City of Dickson or an investigative services firm employed by the City may conduct this inquiry. I authorize such investigation and acknowledge that information on the nature and scope of such a report, if one is made, will be available upon my written request. I agree to hold harmless the city from liability for information that may appear on such reports. I further authorize the City of Dickson or other agency on its behalf to contact references and employers listed, and also authorize release of records or information in connection with a criminal record search in connection with my history, past or present. I understand this application will be given consideration but its receipt does not imply that I will be employed. If I should enter into employment with the City of Dickson, I agree to be subject to rules and regulations governing municipal personnel. I hereby affirm that to the best of my knowledge all information I am furnishing is true and correct. I understand that if any information requested in this application is false or omitted with the effect of misrepresentation, it will be sufficient grounds for my immediate termination from the employ of the City of Dickson.

Name

FIRST NAMELAST NAME

Middle

SIGNATURE OF APPLICANT

Position Applied For

Last

First

Middle

Street

City

State

Zip Code

Email Address

On what date would you be available for work?

Date

If necessary, best time to call:

Contact Number

Have you submitted an application here before?

YesNo

If yes, please give date(s) and position(s):

Have you ever been employed by the City of Dickson?

If yes, please give hire date:

Date

If yes, please give date last employed:

Date

Have you ever worked under another name?

YesNo

If yes, please list name.

Are you over the age of 18?

YesNo

If you are under 18 years old, can you provide a work permit if required?

YesNo

Are you eligible for employment in the United States? (If yes, proof is required if hired.)

YesNo

Will you travel if required?

YesNo

Will you work overtime if required?

YesNo

If they have been explained to you, are you able to meet the attendance requirements of the position?

YesNo

Have you ever been bonded (a requirement of certain positions)?

YesNo

Have you ever been refused bond?

YesNo

Have you ever held a position of trust (handling money or confidential material)?

YesNo

Please provide your drivers license number:

Please provide state that issued drivers license:

NOTE: Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Have you ever pleaded "guilty" or "no contest" to, or been convicted of, a crime?

If yes, please provide dates and details:

1Employer:

Contact Name:

Email:

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Job Title:

Supervisor:

Starting hourly rate or salary:

Ending starting rate or salary:

Work performed:

Reason for leaving:

Can we contact this employer?

YesNo

2Employer:

Contact Name:

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Job Title

Supervisor

Starting hourly rate or salary:

Ending hourly rate or salary:

Work performed:

Reason for leaving:

Can we contact this employer?

YesNo

3Employer:

Contact Name:

Email:

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Job Title:

Supervisor:

Starting hourly rate or salary:

Ending hourly rate or salary:

Work performed:

Reason for leaving:

Can we contact this employer?

YesNo

4Employer:

Contact Name:

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Job Title

Supervisor

Starting hourly rate or salary:

Ending hourly rate or salary:

Work performed:

Reason for leaving:

Can we contact this employer?

YesNo

Explain any gaps in your employment other than those due to personal illness injury or disability:

Have you ever been discharged or requested to resign from a job?

YesNo

If yes, please explain:

High School

Location

Course of Study

Did you graduate?

YesNo

Degree or Diploma

College

Location

Course of Study

Did you graduate?

YesNo

Degree or diploma

Graduate School

Location

Course of Study

Did you graduate?

YesNo

Degree or diploma

Vocational Training / Other

Location

Course of Study

Did you graduate?

YesNo

Languages or Machine Operation

Special Licensure/Certification

Expiration Date of Licensure/Certification

Date

Has license or certification ever been revoked, suspended or voluntarily relinquished?

YesNo

If yes, please explain:

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.

Reference #1 Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Reference #2 Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Reference #3 Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Applicant Statement

By my signature below, I voluntarily and knowingly agree to the following: I understand that any offer of employment may be contingent on the successful completion of a test for alcohol and drug screening and I will upon request sign all necessary consent forms. I agree to take any such physical or medical examinations requested during my employment to determine my "fitness for duty". I understand that all employees, due to the critical nature of their work and the impact on the general public, may be asked to submit to random substance screening at the discretion of the city or in order to comply with mandated testing. I understand that refusal to submit to any physical or medical examination ordered by the city is grounds for rejection for employment or for disciplinary action up to and including immediate discharge. I further understand that any information obtained through such exams may be retained by the city and is exclusively the city's property. I consent to submit to and cooperate in any questioning or searches of my assigned vehicle, if applicable, or locker or storage area, or bags or other belongings on or in the city's property that the city at its discretion may request. I further understand that the refusal to submit to or cooperate in such procedures may be deemed grounds for disciplinary action up to and including immediate discharge. I agree to notify the city if, because of a physical or mental disability, I require an accommodation to complete the application process, to complete any pre-employment testing, or if employment is offered, to perform any essential function of the job for which I have applied. I agree to be employed on a 180 day introductory basis and I understand that I may be dismissed at any time during this period at the discretion of the employer. This also pertains to Police and Fire Department employees who work a 180 day introductory basis after formal training. If employed, I agree to observe all present and subsequently issued personnel rules and policies. These rules and policies are intended to guide the organization in its relationship with its employees. They are not a contract of employment, and I do not construe them as such. I understand that the city may revise policies or procedures, in whole or in part, at any time, with or without notice. I certify that the information given by me in this application is true in all respects, and I agree that if employed and it is found to be false in any way that I may be subject to dismissal without notice, if and when discovered. I authorize the use of any information in this application to verify my statements, and I authorize past employers, references, and any other or all persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages for having furnished such information. I further agree and understand that employment is terminable at the will of either the employee or employer. I understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws. The City of Dickson does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

Signature of Applicant

Date

The City of Dickson is an equal employment opportunity employer and does not unlawfully discriminate on the basis of race, religion, sex, sexual orientation, color, age, national origin, disability, marital status, veteran status, genetic predisposition or any other status protected by applicable law. This voluntary Self-Identification Survey is being provided to you SO the City may comply with government recordkeeping and other legal requirements, including those which require the company to provide the information requested below to the federal government. The completion of this voluntary survey is optional, and the inclusion or exclusion of any data on this form will not subject you to any adverse treatment or affect your employment opportunities with the City of Dickson. In addition, all voluntary surveys are kept in a confidential file, are not part of the application or personnel file, and will only be used in accordance with the provisions of applicable federal law Please print and check on the appropriate line to indicate your selections (Gender/Race-Ethnicity

Name

Date of Application

Date

Position Applied For

Gender

MaleFemale

Race/Ethnicity (check only one)

White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (W)Black or African American(Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. (B/AA)Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. (H/L)Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (A)American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. (AI/AN)Type option 5Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. (NH/OPI)ype option 6Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races. (T/MR)

City of Dickson

APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER

APPLICATION FOR EMPLOYMENT

Employment Experience: (List your recent employer first.)

Education

Special Training or Skills

References

EQUAL EMPLOYMENT OPPORTUNITY SELF-IDENTIFICATION SURVEY