EMPLOYMENT APPLICATION

An Equal Opportunity Employer

Position Applied for

Date

Applicant'sName

Last

First

Middle

Present Address

City

State

Zip

County

Home Phone

Cell Phone

Best time to contact

Email Address

Are you at least 18 years of age?

Yes No

If applying for a police officer position, please provide us with your Date of Birth?

Are you legally authorized to work in the United States?

Yes No

If yes, can you provide proof of eligibility?

Yes No

Have you previously been employed with The Town of Pineville?

Yes No

If yes, please provide:

Dates of employment

Department

Reason for separation

Are you currently employed?

Yes No

If yes, may we contact present employer?

Yes No

Desired Salary Range

Date available for work

Employment desired

Full-Time Only Part-Time Only Full or Part -time

Please state your availability if seeking Part -Time Hours?

Do you have any relatives working for Town of Pineville?

Yes No

If so, provide name & position

Have you ever been convicted of a felony?

Yes No

If yes, please give date, place and nature of
the conviction in the space provided.

Education:

School	Name and Address of School	Did you Graduate? Yes or No	Number of Years Completed	Major & Degree
High School		Yes No
Technical Business or Trade School		Yes No
College (s)		Yes No
Graduate		Yes No

If you did not graduate from high school, did you receive your GED?

Yes No

Do you have any vocational or business training?

Yes No

If yes, please indicate.

Do you have any occupational licenses or certificates?

Yes No

If yes, please indicate.

Please describe any job-related training received in the United States Military, if applicable

Use this space for any additional information that we may find helpful in considering your application
(ex., CDL, Computer training/appl., etc.)

List professional and vocational qualifications(i.e. publications, public speaking, volunteer experience, membership in professional organizations, civic activities and offices held). (You may
exclude memberships, which would reveal gender, race, religion, national origin, age, ancestry, disability or any other protected status.

PRE-EMPLOYMENT DRUG SCREENING

A routine pre-employment drug screening test with a negative test result is required as a condition of employment. (Scheduling will be provided at the appropriate time.)

Please read the following statement and mark yes or no in the space provided.

Have you tested positive or refused to test, on any pre-employment drug or alcohol test for safety sensitive transportation work covered by the Department ofTransportation agency drug and alcohol testing rules during the past two years?

Yes No

EMPLOYMENT HISTORY

Please list your work experience starting with your present or most recent job. Please include service in the Armed Forces and/or self employment. Attach additional sheets if necessary.

EMPLOYER

Job Title

Date

From To

Address

City

State

Zip

Number of people you supervised

Reason for leaving

Duties

Salary

Starting Ending

Telephone

Supervisor

EMPLOYER

Job Title

Date

From To

Address

City

State

Zip

Number of people you supervised

Reason for leaving

Duties

Salary

Starting Ending

Telephone

Supervisor

EMPLOYER

Job Title

Date

From To

Address

City

State

Zip

Number of people you supervised

Reason for leaving

Duties

Salary

Starting Ending

Telephone

Supervisor

REFERENCES

Please list at least two professional references and one personal reference who can attest to your character, skills and abilities

Name	Address	Phone Number	Position	No. of Years Known

APPLICATION CERTIFICATION

I hereby affirm that the information provided on this application and resume, if attached, is true and complete to the best of my knowledge. I also agree that falsified information, misleading 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 hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means it may be terminated any anytime, for any reason at all, at the will of either the Township or the employee.

I hereby understand and agree that any employee handbook or other written material provided to me upon initial employment or at anytime thereafter will not constitute an employment contract, but merely a statement of the present policies of the Town and that such policies of the Town may be amended or discontinued at anytime.

I understand this application for employment shall be considered active for a period not to exceed 6 months.

Yes No