Job Application

Employment Application*

General
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Applicant Information

Name:*

Address*

Phone*

Email*

Position Applied for*

Hourly Wage Desired?*

Are you eligible to work in the US?*

Yes
No

Have you previously worked for the City of Belen?*

Yes
No

Are you at least 18 years or older?*

Yes
No

(If no, you may be required to provide authorization to work.)

Do you know of any relatives that previously worked for the City of Belen?*

Yes
No

If yes, who?*

Have you ever been terminated from employment or asked to resign by an employer?*

Yes
No

If yes, please provide company name and details*

Can you work any shift?*

Yes
No

Can you work overtime, including weekends?*

Yes
No

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*

Yes
No

Date you are available to start?*

Are you currently employed?*

Yes
No

If yes, may we contact your present employer?*

Yes
No

Referral Source

How did you hear about us?*

Walk-In
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Referral
Other

If other, please specify

Previous Employment

Include your last ten (10) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.

Employer

Address

Job Title

Supervisor

Hourly Rate/Salary

Dates Worked

Reason For Leaving

Work Performed

Employer

Address

Job Title

Supervisor

Hourly Rate/Salary

Dates Worked

Reason For Leaving

Work Performed

Employer

Address

Job Title

Supervisor

Job Title

Dates Worked

Reason For Leaving

Work Performed

Have You Ever Been Asked to Leave A Job By An Employer?

Please Explain

Education

High School

Please Include: Name & Location, Number of Years Attended, Degree Received, Subject/Major of School

College or University

Please Include: Name & Location, Number of Years Attended, Degree Received, Subject/Major of School

Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.

References

Three references please, using no more than one family member

Name

Relationship

Phone #

Address

Name

Relationship

Phone #

Address

Name

Relationship

Phone #

Address

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorized all persons listed above (and on the accompanying resume, if any) to give the City of Belen any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and the City of Belen, from liability for any damage that may result from furnishing said information to the City of Belen.

I understand and agree that I may be required to take a drug screening test. I hereby give my voluntary consent for a urine sample to be collected from me and submitted for testing. I also consent to the release of test results to the City of Belen for its use. I understand that any positive drug test result may preclude my employment.

Date*

Signature*

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Email

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Applicant Information

Referral Source

Previous Employment

Education

References

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