Planner

Personal Information

 

Name 

 

Physical Address 

City 

State 

Zip Code 

 

 

Permanent Address 

City 

State 

Zip Code 

 

 

Email Address 

Phone Number 

Secondary Phone Number 

Referred By 

 

 

Employment

Date You Can Start 

 

Are You Currently Employed?

Yes    No 

 

If So, May We Contact Your Employer?

Yes    No 

 

Are You Legally Authorized To Work in the U.S.?

Yes    No 

 

Have You Applied with the Town of Pulaski Before?

Yes    No 

 

If So, When? 

 

Have You Worked for the Town of Pulaski Before?

Yes    No 

 

If So, When? 

 

Reason for Leaving

 

How Did You Find Out About This Position?

 

 

Education History

High School

Name of School 

Years Attended 

Did You Graduate?

Yes    No 

 

Subjects Studied 

 

 

College

Name of School 

Years Attended 

Did You Graduate?

Yes    No 

 

Subjects Studied 

 

Trade, Business or Correspondence School

Name of School 

Years Attended 

Did You Graduate?

Yes    No 

 

Subjects Studied 

 

Subject of Special Study/Research Work

 

Special Training, Certifications, Licenses

 

Special Skills, Foreign Languages, Etc.

 

 

 

Military Service Record

Have You Ever Served in the U.S. Armed Forces?

Yes    No 

 

Branch of Service 

 

Discharge Date 

 

Rank 

 

 

 

Former Employers (List your last three places of employment, starting with the most recent)

Name of Present or Last Employer 

 

Address 

City 

State 

Zip Code 

 

Starting Date 

Leaving Date 

 

Job Title 

 

May We Contact Your Supervisor?

Yes    No 

                   

Name of Supervisor 

Supervisor's Title 

Phone Number 

 

Description of Work

 

Reason for Leaving

 

 


 

 

Name of Previous Employer 

 

Address 

City 

State 

Zip Code 

 

 

Starting Date 

Leaving Date 

 

 

Job Title 

 

May We Contact Your Supervisor?

Yes    No 

 

Name of Supervisor 

Supervisor's Title 

Phone Number 

 

Description of Your Work

 

Reason for Leaving

 

 


 

 

Name of Previous Employer 

 

Address           

City        

State 

Zip Code 

 

 

Starting Date           

Leaving Date 

 

 

Job Title 

 

May We Contact Your Supervisor?

Yes    No                          

 

Name of Supervisor           

Supervisor's Title           

Phone Number 

 

Description of Your Work

 

Reason for Leaving

 

 

References - Please List Three Professional Reference That We May Contact

 

Name      

Address      

Relationship      

Phone Number 

 

 

Name      

Address      

Relationship      

Phone Number 

 

 

Name      

Address      

Relationship      

Phone Number 

 

Special Purpose Questions

I understand and agree that, in the event I am offered this position, I may be required to take a physical examination, background check and/or drug test, as a condition of the hiring process or continued employment. I agree to consent to take such test(s) at such time as designated by the Town of Pulaski and to release the Town of Pulaski, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s), other than claims related to privacy violations and/or discrimination under applicable federal and state laws. I understand that all potential employees are required to undergo a physical exmination, background check and/or drug test and that, in compliance with federal law, the records of such tests will be kept confidential and the information obtained will not be used to discriminate on the basis of disability, health problems, or medical conditions. 

Yes    No 

 

Authorization

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.”

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Date         

Electronic Signature 

 

We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, genetic information, national origin, citizenship status, physical or mental disability, or any other legally protected status. Completing this application does not obligate us in any way. 

If you require an accommodation in order to participate in any phase of the application process, please contact the Town of Pulaski Human Resources office at (540) 994-8642 or email [email protected] 

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