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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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