CIVIL SERVICE RECRUITMENT - City of Cheney

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Application for EmploymentPosition Applied For: _____________________________________NameLast First MiddleCurrent Street AddressP.O. Box or StreetCity State ZipPhoneSocial Security No.Education and TrainingCircle highest year completed 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 G E D 1 3 1 4 1 5 1 6 1 7 1 8 1 9Type of SchoolName/Address Major Subject DegreeHi gh S c h oo lC ol le geC ol le geG r a d u a t e S ch oolB u s i n es s , Vocation a l,Trade or Ot h e rDriver’s License No. S t a t e E xp i r a t i onA r e y o u a U . S . C i t i ze n, o r , d o y o u h a v e a V i s a p e r m i t t i n g y o u t o w o r k i n t h e U . S . ? ( D o c u m e n t a t i o n of a u t h o r i za t i o n t o w o r k i n t h eU . S . w i l l b e r e q u i r e d i f a n of f e r of e m p l o y m e n t i s m a d e a n d a c c e p t e d . )YesNoDo you wish to claim veteran’s preference? Yes NoI f s o, p lease attach a cop y o f DD F orm 214 or ot h e r p r oo f o f d i s c h a r ge.Note : Veteran’s pre fe r e n c e p oi n t s a r e a ll owed on l y i n c i vi l s e r vi c e p os i t i on s .Describe any special i z e d t r a ining, apprenticeships, s ki l l s a n d e xtra curricular activi t i es . I n c l u d e a ll p r of e s si onal license s ,c e r t i f i c a t es or registrations y ou hol d . I n c l u d e e xp i r a t i on d a t e ( s ) a n d i s s ui n g s ta t e ( s ) .Have you been convicted of any offense other than minor traffic violations within the last seven years? Yes _____ No _____If yes, explain below. Such conviction(s) may be relevant if job related, but does not necessarily bar you from employment.609 Second Street • Cheney, WA 99004 • Phone (509) 498-9200 • Fax (509) 498-9206 • www.cityofcheney.org
Employment HistoryList your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in thecomment section. Additional employment may be listed if relevant.Employer Telephone Dates Employed Immediate Supervisor and Title( ) From ToAddressReason for LeavingHourly Rate/SalaryJob Title Starting Ending May we contact for reference?Summarize the nature of the work performed and job responsibilities Yes No LaterEmployer Telephone Dates Employed Immediate Supervisor and Title( ) From ToAddressReason for LeavingHourly Rate/SalaryJob Title Starting Ending May we contact for reference?Summarize the nature of the work performed and job responsibilities Yes No LaterEmployer Telephone Dates Employed Immediate Supervisor and Title( ) From ToAddressReason for LeavingHourly Rate/SalaryJob Title Starting Ending May we contact for reference?Summarize the nature of the work performed and job responsibilities Yes No LaterComments (including explanation of any gaps in employment)ReferencesList name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personalreferences who are not related to you.Name Address Telephone Years Known( )( )( )It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from theemployer’s service if I have been employed. I give the Employer the right to investigate all references and to secure additional information about me, if job related. I herebyrelease from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. Iunderstand that if I receive a Conditional Offer of Employment for a position where I have unsupervised access to children, developmentally disabled persons, or vulnerableadults, the City of Cheney is required to complete a thorough background check as required by the Child/Adult Abuse Information Act. I have read the Position OpeningAnnouncement and I can perform the essential functions of the position for which I am applying, with or without accommodation. I understand that just as I am free to resignat any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative ofthe Employer has the authority to make any assurances to the contrary.Signature of ApplicantDateAttach any additional information or job related skills you would like us to consider. The City of Cheney is a drug free, Equal Opportunity Employer and does not unlawfully discriminateon the basis of race, sex, age, color, sexual orientation, religion, national origin, marital status, genetic information, veteran’s status, disability, or any other basis prohibited by federal,state, or local law.
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CIVIL SERVICE RECRUITMENT - City of Cheney

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