Welcome to Town of Carbondale

TOWN OF CARBONDALE

APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer

We do not discriminate on the basis of race, religion, national origin, sex, age, disability, or any other status protected by law or regualtion. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Job Applied For: Are you seeking: Full-time Part-time Temporary employment?
Last Name: First Name:   Middle Name:
Present Street Address:
City:    State
Are you 18 years of age or older? Yes No
Email Address:
Social Security # XXX-XX-
If hired can you furnish proof that you are eligible to work in the U.S.? Yes No
Have you ever applied here before? Yes No
Were you ever employed here? Yes No

Have you ever been convicted of any law violation? Include any plea of "guilty" or "no contest". Exclude minor traffic violations.
Yes No If yes, give details below. A conviction will not necessarily disqualify an applicant for employment.

If employed, do you expect to be engaged in any additional business or employment outside of our job? Yes No
If yes, give details below.

For Driving Jobs ONLY: Do you have a valid driver's license? Yes No
Driver's License Number   Class of License   State Licenses In
Have you had your driver's license suspended or revoked in the last 3 years? Yes No
If yes, give details below.

List professional, trade, business or civic acitvities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, age, disibility or other protected status.)

LIST NAME AND ADDRESS OF SCHOOLS
HighSchool/GED: #YearsCompleted:Diploma/Degree/Certificate:SubjectsStudied:
College/Univeristy:#YearsCompleted:Diploma/Degree/Certificate:SubjectsStudied:
Vocational/Technical:#YearsCompleted:Diploma/Degree/Certificate:SubjectStudied:

What skills or additional training do you have that relate to the job for which you are applying?

What machines or equiptment can you operate that relate to the job for which you are applying?

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers.

Employer 1
Name of Employer:
Employer Address:
City, State, Zip Code:
Supervisor(s):
Telephone:
Job Title and Duties:
Dates of Employment (MO/YR):
Pay Start $: Pay Final $:
Reason for Leaving:

Employer 2
Name of Employer:
Employer Address:
City, State, Zip Code:
Supervisor(s):
Telephone:
Job Title and Duties:
Dates of Employment (MO/YR):
Pay Start $: Pay Final $:
Reason for Leaving:

Employer 3
Name of Employer:
Employer Address:
City, State, Zip Code:
Supervisor(s):
Telephone:
Job Title and Duties:
Dates of Employment (MO/YR):
Pay Start $: Pay Final $:
Reason for Leaving:

Employer 4
Name of Employer:
Employer Address:
City, State, Zip Code:
Supervisor(s):
Telephone:
Job Title and Duties:
Dates of Employment (MO/YR):
Pay Start $: Pay Final $:
Reason for Leaving:

Have you worked or attended school under any other names? Yes No
   If yes, give names:
Are you presently employed? Yes No
   If yes, whom do you suggest we contact?
Have you ever been fired from a job or asked to resign? Yes No
   If yes, please explain:

Give three references, not relatives or forner employers.

Name:
Address:
Phone:

Name:
Address:
Phone:

Name:
Address:
Phone:

Attach a resume:
Attach a cover letter:

PLEASE READ EACH STATEMENT CAREFULLY AND CHECK EACH BOX IN AGREEMENT BEFORE SUBMITTING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from futher consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and oponions that may be usedful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I may be required to successfully pass a drug screening examination. I hearby consent to a pre-and/or post-employment drug screen as a condition of employment, if required.

I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capavbility to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NO GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE TOWN MANAGER OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WIRTING, SIGNED BY THE TOWN MANAGER AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Signature:

Town ofCarbondale

Submit an Application for Employment