City Job Application Form – City of Chamberlain, South Dakota

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Name *

First

Last

Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Email *

Phone *

Date of Birth *

Position Desired *

Can you perform the essential functions of the position for which you are applying? *

Yes
No

When would you be available to begin work? *

Are you legally eligible to be employed in the United States? *

Yes
No

(Proof of identity and eligibility will be required upon employment)

Are you over the age of 18 years? *

Yes
No

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

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Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last seven years? *

Yes
No

(A conviction will not necessarily result in the denial of employment.)

If yes, please explain:

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Have you ever worked for the City before? *

Yes
No

If yes, where?

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Do you have any relatives or friends who work for the City? *

Yes
No

If yes, who and where do they work?

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Have you ever done any volunteer work? *

Yes
No

If yes, describe:

(Omit any information that reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities)

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When are you available to work: *

Days
Nights
Weekends
Full time

If you cannot work full time, please explain:

Please describe the dates and times you are available *

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Are you presently employed? *

Yes
No

If yes, may we contact your employer? *

Yes
No

If presently employed, why are you considering leaving? *

Put N/A if not presently employed.

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Do you belong to any professional, trade, business or civic organizations that deal with the position for which you are applying? *

Yes
No

If yes, please explain and list offices held:

(Omit any organization which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)

Account for any full month since leaving school (high school or college) that you were not working: *

Please put the month, year and reason.

Education

Put N/A if not attended

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High School *

Name and Location

High School *

Course of Study

High School *

Years Completed

High School *

Degree Received

College *

Name and Location

College *

Course of Study

College *

Years Completed

College *

Degree Received

Vocational or Trade Scool *

Name and Location

Vocational or Trade School *

Course of Study

Vocational or Trade School *

Years Completed

Vocational or Trade School *

Degree Received

Graduate Work *

Name and Location

Graduate Work *

Course of Study

Graduate Work *

Years Completed

Graduate Work *

Degree Received

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Have you completed any special courses, seminars and/or training that would enable you to perform the position for which you are applying? *

Yes
No

If yes, please describe:

List academic honors, extracurricular activities, offices held, etc. in high school or college:

(Omit any which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)

Employment

Start with your present or most recent position

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Name of Employer *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

Finish Date or Current *

Beginning Pay Rate *

End Pay Rate *

Describe The Work Performed *

Phone *

Supervisor's Name *

Supervisor's Title *

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Name of Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

Finish Date or Current

Beginning Pay Rate

End Pay Rate

Describe The Work Performed

Phone

Supervisor's Name

Supervisor's Title

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Name of Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

Finish Date or Current

Beginning Pay Rate

End Pay Rate

Describe The Work Performed

Phone

Supervisor's Name

Supervisor's Title

Personal References

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Name *

First

Last

Phone *

Occupation *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Name *

First

Last

Phone *

Occupation *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Name *

First

Last

Phone *

Occupation *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

APPLICANTS WILL RECEIVE CONSIDERATION FOR POSITIONS, WITHOUT REGARD TO RACE, COLOR, RELIGION, AGE, SEX, EXCEPT WHERE SEX IS A BONAFIDE OCCUPATIONAL QUALIFICATION, SEXUAL ORIENTATION, MARITAL STATUS, INDIVIDUALS WITH DISABILITIES, AND EQUALLY TO DISABLED VETERANS AND VETERANS OF THE VIETNAM ERA.

IMPORTANT, PLEASE READ AND SIGN

I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this Application for Employment can be grounds for termination from the company or its subsidiaries. I understand that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice.

Sign Electronically Here *