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*

Phone Area Code-Phone 3-Phone 4 ext Extension

Cell Phone Number*

Phone Area Code-Phone 3-Phone 4 ext 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*

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*

Phone Area Code-Phone 3-Phone 4 ext 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*

Phone Area Code-Phone 3-Phone 4 ext 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

Phone Area Code-Phone 3-Phone 4 ext Extension

Job Title

Please Do Not Complete The Following Field

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*

Phone Area Code-Phone 3-Phone 4 ext 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*

Phone Area Code-Phone 3-Phone 4 ext 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

Phone Area Code-Phone 3-Phone 4 ext 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

Contact Information

Additional Information

Education

Work Experience - Most Recent Employer

Additional Employment History

References

Dialog Title