Water Department Maintenance Position

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I understand that when information is requested of me on this application, I must provide it accurately and completely unless otherwise prohibited by law. I understand that any material omission, or false or misleading statement in this application may result in denial of employment, or, if I am employed, to discharge, no matter when discovered. I understand that this also applies, without limitation to information which I leave unanswered or blank or partially so on this application. I also understand that Loves Park's failure to discover or act on any material omission, false, misleading, unanswered or blanks which I leave on my application does not waive, stop or bar Loves Park from taking action (including, without limitation, termination) against me at any other time.

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The City of Loves Park does not discriminate on the basis of race, color, age, religion, sex/ gender, sexual orientation and/or expression, ancestry, national origin, military or veteran status, disability, or any other characteristic protected by applicable federal, state, or local law. Loves Park is an equal employment opportunity employer and all qualified applicants will be given an equal opportunity for possible selection and decisions are based on job-related factors. Any complaints of discrimination will be investigated promptly and thoroughly and in a confidential manner.

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Name*

First Middle Last

Other Name

List any other name you have ever been known by.

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Are any of your relatives employed by the City of Loves Park?

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No

Please provide their information

Full Name	Title	Department

High School

Have you earned a high school diploma or G.E.D. certificate?

Yes
No

School Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List years attended

Graduated

Yes
No

College or University

School Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List years attended

Graduated

Yes
No

Degree or Concentration

Additional College or University (if applicable)

1. School Name (Additional)

1. Address (Additional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. List years attended (Additional)

1. Graduated (Additonal)

Yes
No

1. Degree or Concentration (Additional)

2. School Name (Additional)

2. Address (Additional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. List years attended (Additional)

2. Graduated (Additional)

Yes
No

2. Degree or Concentration (Additional)

3. School Name (Additional)

3. Address (Additional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3. List years attended (Additional)

3. Graduated (Additional)

Yes
No

3. Degree or Concentration (Additional)

4. School Name (Additional)

4. Address (Additional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

4. List years attended (Additional)

4. Graduated (Additional)

Yes
No

4. Degree or Concentration (Additional)

5. School Name (Additional)

5. Address (Additional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

5. List years attended (Additional)

5. Graduated (Additional)

Yes
No

5. Degree or Concentration (Additional)

Other Education (if applicable/please specify)

School Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Education

Total years of study or Number of years attended

Graduated

Yes
No

Degree or Concentration

Specialized Training and Skills

Certification

Licenses

Skills

Employment History

Present or Most Recent Employment

Name of Employer

Address of Employer

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Job Title

Start Date

End Date

Hours Per Week

Supervisor's Name

Supervisor's Phone

Supervisor's Email

Job Duties

Reasons for Leaving

Do you object to our contacting them?

Yes
No

Additional Previous Employers for Last 10 Years (if applicable)

Past Employment

Name of Employer	Address of Employer	Job Title	Start/End Date

Additional employment experiences

List any other employment experiences that you have, which you believe are related to the job.

Employment Gaps

Please explain any gaps in your employment

Additional Open-Ended Questions

Have you ever served in the U.S. Military?

Yes
No

Date of Discharge

Type of Discharge

Are you now, or were you ever a member of the U.S. Reserve Forces or National Guard?

Branch of Service

Rank

Unit

Date Entered

Were you ever discharged from reserve service?

Have you ever been terminated from a job?

Yes
No

If yes, please explain.

Have you ever applied to the City Loves Park

Yes
No

Have you ever taken a Civil Service Exam?

Yes
No

Where

When

Where

As a driver, have you ever been involved in a traffic accident?

Yes
No

If yes, please explain by including the date, location, and nature of the accident, with things like personal injury property damage, etc.

Have you been charged or convicted of a criminal offense?

Yes
No

If yes, please list the police agency, crime charged, and disposition of the case.

Have you ever been placed on probation for a criminal offense?

Yes
No

If yes, please explain.

Have you ever received a traffic citation?

Yes
No

If yes, please list all traffic citations you have received in the last 5 years (include date, city/town, state, and name of violation)

Have you ever been sued?

Yes
No

If yes, please explain.

Have you ever been convicted of a felony?

Yes
No

Please supply 3 personal references

Reference #1

Name

Relationship

No. of years acquainted

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Reference #2

Name

Relationship

No. of years acquainted

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Reference #3

Name

Relationship

No. of years acquainted

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Residence History

Additional Addresses

Address	From Date	To Date

Proof of Citizenship Form (Proof of Authorization to work in the US)

Are a naturalized U.S. Citizen?

Yes
No

Are authorized to work in U.S.?

Yes
No

Alien Number

Naturalization Certificate Number

Location of Issuance

Date of Issuance

Official Name Recorded on Certificate

First Middle Last

Voluntary Equal Employment Opportunity Form

Completion of this form is completely voluntary and will have absolutely no impact on your application. The information requested on this form is being collected to ensure fairness of the selection procedures and will be processed separately from the remainder of your application. Your participation in completing this voluntary form would be greatly appreciated.

What is your date of birth?

What is your gender?

How did you hear about this job opening

Certification of Honesty

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed my application. I understand that my omission or misstatement of material fact on this application or on any document used to secure employment shall result in my withdrawal from consideration for employment, or immediate termination from employment.

Yes

I agree to electronically sign this document and assert that I have read, understand, and agree to the terms and conditions.

Yes

You may request a reasonable accommodation to facilitate the application process, including a reasonable accommodation to enable you to participate in the interview process. Applications requesting a reasonable accommodation will be given the same considerations as other applicants.

This application is a questionnaire regarding possible employment. It is not an offer of employment. Loves Park, in its sole discretion, will make a later decision as to whether or not it will make an offer of employment to you. If there is a later decision by Loves Park to hire you, Loves Park will notify you and any later employment is "at will" which means that employment can be terminated at any time with or without cause, reasons or notice."

Street Department Maintenance/Mechanic Position

High School

College or University

Additional College or University (if applicable)

Other Education (if applicable/please specify)

Specialized Training and Skills

Employment History

Present or Most Recent Employment

Additional Previous Employers for Last 10 Years (if applicable)

Additional employment experiences

Employment Gaps

Additional Open-Ended Questions

Please supply 3 personal references

Reference #1

Reference #2

Reference #3

Residence History

Proof of Citizenship Form (Proof of Authorization to work in the US)

Voluntary Equal Employment Opportunity Form

Certification of Honesty

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