Action Center / Application for Employment / Washington, IN

Contact Information

Email

Position(s) Applied For

Date of Application

MonthDay Year,

Last Name

First Name

Middle Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Cell Phone Number

Cell Phone Number Area Code-Cell Phone Number Prefix-Cell Phone Number Line Number ext Cell Phone Number Extension

Best time to contact you at home

Additional Information

Education

High School Name

High School Address

High School Course of Study

High School Year Completed

High School Degree

Undergraduate College Name

Undergraduate College Address

Undergraduate College Course of Study

Undergraduate Year Completed

Undergraduate College Degree

Please Do Not Complete The Following Field

Other Name and Address

Other Course of Study

Other Year Completed

Other Degree

Describe any specialized training apprenticeships, skills, and extra-curricular activities.

Summarize special job-related skills and qualifications acquired from employment or other experience.

Experience

PC / MAC

Work Experience - Most Recent Employer

Employer

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Job Title

Supervisor

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Date Employment Started

MonthDay Year,

Date Employment Ended

MonthDay Year,

Reason for Leaving

Hourly Rate / Salary

Work Performed

Additional Employment History

Employer

Employer Address

Supervisor

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Job Title

Date Employment Started

MonthDay Year,

Date Employment Ended

MonthDay Year,

Reason for Leaving

Hourly Rate/ Salary

Work Performed

Employer

Employer Address

Supervisor

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Job Title

Date Employment Started

MonthDay Year,

Date Employment Ended

MonthDay Year,

Reason for Leaving

Hourly Rate / Salary

Work Performed

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

Yes

No

If yes, please describe

References

Reference 1

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Reference 1 Phone Number

Reference 1 Phone Number Area Code-Reference 1 Phone Number Prefix-Reference 1 Phone Number Line Number ext Reference 1 Phone Number Extension

Your Relationship to this Person

Reference 2

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Reference 2 Phone Number

Reference 2 Phone Number Area Code-Reference 2 Phone Number Prefix-Reference 2 Phone Number Line Number ext Reference 2 Phone Number Extension

Your Relationship to this Person

Reference 3

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Reference 3 Phone Number

Reference 3 Phone Number Area Code-Reference 3 Phone Number Prefix-Reference 3 Phone Number Line Number ext Reference 3 Phone Number Extension

Your Relationship to this Person

Do you hold a license or professional certification? If yes, please specify.

Employment: Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application for employment is true and complete. I authorize you to verify any of the information concerning my employment, education, driving record, criminal history, credit history or medical history with the appropriate individuals, companies, institutions or agencies and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment. If hired, I agree I will serve at the will of the City of Washington and I agree that I shall be bound by the rules, policies, regulations and terms and conditions of employment of the city of Washington as they are from time-to-time changed with or without notice to me. I agree that either party may terminate the employment relationship, with or without cause, at any time for any reason. I agree that these arrangements may only be altered in writing directed to me personally by the Mayor of the City of Washington. I further agree that if! should bring any action or claim arising out of my employment against the City of Washington in which the City of Washington prevails, I will pay to the City of Washington any and all costs incurred by the City of Washington in defense of said claims or actions, including attorney’s fees. I further agree that my employment is conditional until such time as the results of my pre-employment physical (if such physical is required) are known.

Electronic Signature

If you wish to submit a resume with this required application, please email it to debbie.neukam@washingtonin.us.

The City of Washington, Indiana

Small City... Big Possibilities

Application for Employment

About this Form

Contact Information

Additional Information

Education

Work Experience - Most Recent Employer

Additional Employment History

References

Dialog Title