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C I T Y O F D E C A T U R
APPLICATION FOR EMPLOYMENT
201 East Walnut ~ P.O. 1299, Decatur, TX 76234
Telephone: 940-393-0205 ~ Fax: 940-627-1341
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INSTRUCTIONS: Please complete in full. Print or type all information. False, misleading or
incomplete information is cause for rejection or dismissal. Employment is subject to applicant sat-
isfying the Citys requirements as to character, employment testing, employment references, and
post-offer physical examination and drug screen. This application, along with any attachments,
becomes the property of the City of Decatur. An application is required for each position you apply.
All applicants meeting the Citys minimum qualifications will be considered for employment without
regard to race, religion, sex, national origin, age or the presence of a non-job-related medical con-
dition or disability.
DATE JOB APPLYING FOR:
DATE YOU ARE AVAILABLE TO START WORK
IF OFFERED THE POSITION, WILL YOU ACCEPT THE STARTING SALARY? Yes No
IF NO, WHAT SALARY IS DESIRED?
HOW DID YOU LEARN ABOUT US AND/OR THE POSITIONS FOR WHICH YOU APPLIED?
Professional Organization/Network Walk-In Newspaper
City Employee
Decatur Website Friend Relative Other
NAME
Last First M.I.
ADDRESS
STREET APT # CITY STATE ZIP
TELEPHONE: Home: Work/Cell:
E-MAIL: Home : Work:
ARE YOU CURRENTLY ON LAY-OFFSTATUS & SUBJECT TO RECALL?…………. Yes No
ARE YOU CURRENTLY EMPLOYED?……………………………………………………….. Yes No
ARE YOU ABLE TO TRAVEL IF THE JOB REQUIRES TO DO SO?…………………….. Yes No
DO YOU OR YOUR SPOUSE HAVE ANY FRIENDS/RELATIVES WHO
WORK FOR DECATUR?……………………………………………………………... Yes No
If Yes: Name
Dept Relationship
HAVE YOU EVER BEEN EMPLOYED BY DECATUR?…………………………………….. Yes No
Dept: Reason for Leaving
Dates of Employment: Starting Ending
HAVE YOU PREVIOUSLY FILED AN APPLICATION WITH DECATUR?………………... Yes No
PLACE AN XTHROUGH ANY OF THE FOLLOWING THAT YOU ARE UNABLE OR UNWILLING TO WORK:
EVENINGS DEEP NIGHTS WEEKENDS HOLIDAYS ON CALL PART-TIME FULL-TIME TEMPORARY OVERTIME
PERSONAL
HR-001 Rev. 10-30-2006
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INSTRUCTIONS: List all employers for which you have worked in the last ten (10) years, starting with the most recent
or current employer. Complete all blanks. Please print or type. Describe all job duties performed which demonstrate
your qualifications for the position for which you are applying. BE ADVISED THAT A RESUME IS NOT A SUBSTITUTE
FOR THE INFORMATION REQUESTED BELOW. A resume may be attached as a supplement to the information
given below. Failure to provide the required information may result in disqualification from active consideration.
NEXT PREVIOUS EMPLOYER: Starting Date:
ADDRESS: PHONE Ending Date:
CITY STATE ZIP
NAME OF IMMEDIATE SUPERVISOR: Starting Salary:
YOUR POSITION: Ending Salary:
REASON FOR DESIRING CHANGE:
DESCRIBE ALL DUTIES PERFORMED IN THIS POSITION ESPECIALLY THOSE WHICH DEMONSTRATE YOUR QUALIFICA-
TIONS FOR THE POSITION FOR WHICH YOU ARE CURRENTLY APPLYING. PLEASE BE SPECIFIC:
NEXT PREVIOUS EMPLOYER: Starting Date:
ADDRESS: PHONE Ending Date:
CITY STATE ZIP
NAME OF IMMEDIATE SUPERVISOR: Starting Salary:
YOUR POSITION: Ending Salary:
REASON FOR DESIRING CHANGE:
DESCRIBE ALL DUTIES PERFORMED IN THIS POSITION ESPECIALLY THOSE WHICH DEMONSTRATE YOUR QUALIFICA-
TIONS FOR THE POSITION FOR WHICH YOU ARE CURRENTLY APPLYING. PLEASE BE SPECIFIC:
NEXT PREVIOUS EMPLOYER: Starting Date:
ADDRESS: PHONE Ending Date:
CITY STATE ZIP
NAME OF IMMEDIATE SUPERVISOR: Starting Salary:
YOUR POSITION: Ending Salary:
REASON FOR DESIRING CHANGE:
DESCRIBE ALL DUTIES PERFORMED IN THIS POSITION ESPECIALLY THOSE WHICH DEMONSTRATE YOUR QUALIFICA-
TIONS FOR THE POSITION FOR WHICH YOU ARE CURRENTLY APPLYING. PLEASE BE SPECIFIC:
MOST RECENT EMPLOYER: Starting Date:
ADDRESS: PHONE Ending Date:
CITY STATE ZIP
NAME OF IMMEDIATE SUPERVISOR: Starting Salary:
YOUR POSITION: Ending Salary:
REASON FOR DESIRING CHANGE: May we contact?
DESCRIBE ALL DUTIES PERFORMED IN THIS POSITION ESPECIALLY THOSE WHICH DEMONSTRATE YOUR QUALIFICA-
TIONS FOR THE POSITION FOR WHICH YOU ARE CURRENTLY APPLYING. PLEASE BE SPECIFIC:
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CIRCLE THE HIGHEST GRADE COMPLETED:
Grade School High School College Graduate School
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 1 2 3 4
PLEASE LIST ANY PROFESSIONAL ASSOCIATIONS, LICENSING AND/OR CERTIFICATION WHICH YOU PARTICI-
PATE IN OR HAVE ACQUIRED:
School/College Name
And
City Where Located
Address
Type of Degree Granted
(BBA, BS, BA, AS, MPA)
Major & Minor
Circle Last
Year of
Education
Completed
For Each
Total
Number of
Hours
Completed
Number of
Hours
Completed
in Field
Diploma/Degree
Granted
&
GPA
High School
Type:
Major:
Minor:
9 10 11 12
Diploma? Yes No
GED? Yes No
GPA _______
College/University Type:
Major:
Minor:
1 2 3 4
Degree? Yes No
GPA _______
College/University
Type:
Major:
Minor:
1 2 3 4
Degree? Yes No
GPA _______
Graduate School
Type:
Major:
Minor:
1 2 3 4
Degree? Yes No
GPA _______
Business/Trade
Type:
Major:
1 2 3 4
PLEASE DESCRIBE ANY COURSES, PROGRAMS OR OTHER ACTIVITIES WHICH YOU PARTICIPATED IN THAT
RELATE TO THE POSITION FOR WHICH YOU ARE APPLYING: ____________________________________________
EXPLAIN IN DETAIL ANY TIME LAPSES IN YOUR EMPLOYMENT RECORD DUE TO UNEMPLOYMENT
OR OTHER REASONS
SERVICE IN THE U.S. ARMED FORCES:
1. HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES? YES NO
A. A COPY OF FORM DD214 MUST BE PROVIDED TO THE HUMAN RESOURCES OFFICE PRIOR
TO TESTING OR INTERVIEWING IN ORDER TO RECEIVE MILITARY POINTS.
B. ANY JOB RELATED EXPERIENCE
2. ARE YOU PRESENTLY A MEMBER OF A MILITARY RESERVE UNIT?
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The following information is requested for Human Resources use only. INSTRUCTIONS: Answer all
questions. Omitted questions will be grounds for disqualification of your application. Falsification of infor-
mation is grounds for disqualification of your application or immediate termination of employment. Please pro-
vide three (3) professional and three (3) personal references.
REFERENCES #1 PROFESSIONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email: ___
REFERENCES #2 PROFESSIONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email: ___
REFERENCES #3 PROFESSIONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email: __:
REFERENCES — #1 PERSONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email: __
REFERENCES #2 PERSONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email:
REFERENCES #3 PERSONAL:
Name: Relationship:
Company: Title:
Address:
Telephone: Fax: Email:
FAILURE TO SIGN WILL RESULT IN AN INCOMPLETE APPLICATION.
Name:
Signature: Date:
PERSONAL REFERENCES
PROFESSIONAL REFERENCES
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signature
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IMPORTANT - PLEASE READ
I understand that all information submitted and considered is subject to verification. I understand and
hereby authorize and give permission for the City of Decatur to conduct verification and/or investigations
including but not limited to credit history, criminal history, driving record, character, employment history,
reputation and any other job-related investigations as are necessary to determine my qualifications for
employment. I authorize the schools, persons, previous employers and other organizations to provide the
City with any and all information about me. I hereby release any such schools, persons, previous employ-
ers and other organizations or individuals from any and all liability for damages of whatever kind which
may result to me, including but not limited to, claims for negligence, which they might otherwise incur as a
result of disclosing the information about me.
I understand that if I am offered employment with the City of Decatur, I will be required to take a post-
offer physical exam which will include drug testing. Any offer of employment that I may receive will be
conditioned upon the results of the post-offer physical exam. In addition, positive results of the post-offer
drug test will disqualify me from employment. I also understand that if I become employed with the City of
Decatur, I will be required to comply with the Citys drug testing policies and procedures.
I understand also that I am required to abide by all rules and regulations of the City and department. The
City shall have the right to amend, modify or revoke its rules and regulations at any time. I will familiarize
myself promptly with such rules and regulations now or hereafter in effect.
In consideration of my employment, I agree to conform to the rules and regulations of the City of Decatur.
I understand that my employment and compensation can be terminated with or without cause, and with or
without notice, at any time, at the option of the City or myself. I understand that no employee or officer of
the City has any authority to enter into any agreement for employment for any specified period of time or
to make any agreement contrary to the foregoing.
I understand that decisions to fund steps, merit increases, or salary adjustments are made annually by the
City Council and the existence of a pay plan or other document showing steps, merit increases, or ranges,
does not guarantee a timed progression through a grade.
I certify that all statements and answers to all questions in this application are true, complete and correct
and are made in good faith. I understand that falsification of any answers I have given will have serious
consequences, including disqualification for employment and/or termination of employment without right
of appeal.
My employment shall be in accordance with the terms of this application, City rules and regulations and
any amendments thereto. The City shall have the right to amend, modify or revoke its rules and regula-
tions at any time. I will familiarize myself promptly with such rules and regulations now or hereafter in ef-
fect. Failure to sign the application will result in an incomplete application and will be disqualified.
Printed Name
Signature Date
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signature
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The following information is requested for Human Resources use only. This form will not be forwarded to the department in
which you are applying.
INSTRUCTIONS: Answer all questions. Omitted questions will be grounds for disqualification of your application. Falsification
of information is grounds for disqualification of your application or immediate termination of employment. All certification statements
agreed to on the general City of Decatur application apply to information given here.
WITHIN THE LAST FIVE (5) YEARS, HAVE YOU EVER BEEN DISCHARGED OR DISCIPLINED BY AN EMPLOYER FOR:
TARDINESS……………………………………….. YES NO
DISCHARGED DISCIPLINED EMPLOYER
JOB ABANDONMENT……………………………. YES NO DISCHARGED DISCIPLINED EMPLOYER
OTHER ATTENDANCE-RELATED PROBLEMS YES NO DISCHARGED DISCIPLINED EMPLOYER
FIGHTING………………………………………….. YES NO DISCHARGED DISCIPLINED EMPLOYER
ASSAULT…………………………………………... YES NO DISCHARGED DISCIPLINED EMPLOYER
INSUBORDINATION………………………………. YES NO DISCHARGED DISCIPLINED EMPLOYER
VIOLATING SAFETY RULES……………………. YES NO DISCHARGED DISCIPLINED EMPLOYER
EXPLAIN ANY YESRESPONSES GIVEN ABOVE:
HAVE YOU EVER BEEN DISCIPLINED OR DISCHARGED BY AN EMPLOYER FOR:
THEFT………………………………………………. YES NO DISCHARGED DISCIPLINED EMPLOYER
BEING UNDER THE INFLUENCE OF ALCOHOL
OR DRUGS AT WORK…………………………. YES NO
DISCHARGED DISCIPLINED EMPLOYER
POSSESSION OFALCOHOL OR DRUGS
WHILE AT WORK……………………………….. YES NO
DISCHARGED DISCIPLINED EMPLOYER
SALE OF ALCOHOL
OR DRUGS AT WORK…………………………. YES NO
DISCHARGED DISCIPLINED EMPLOYER
UNAUTHORIZED REMOVAL OF
EMPLOYERS PROPERTY……………………. YES NO
DISCHARGED DISCIPLINED EMPLOYER
FALSIFYING EMPLOYMENT,
EDUCATION, AND/OR APPL. INFO……………. YES NO
DISCHARGED DISCIPLINED EMPLOYER
SEXUAL HARASSMENT OR
SEXUAL IMPROPRIETY……………………….. YES NO
DISCHARGED DISCIPLINED EMPLOYER
HAVE YOU EVER BEEN DISCHARGED (FIRED) FROM A JOB? YES NO EMPLOYER
HAVE YOU EVER BEEN CONVICTED OF ANY MISDEMEANOR OR FELONY EXCLUDING MINOR
TRAFFIC OFFENSES?……………………………………………………………………………………………………. YES NO
HAVE YOU EVER BEEN PLACED ON DEFERRED ADJUDICATION, DEFERRED PROBATION
OR DEFERRED PROSECUTION?………………………………………………………………………………………. YES NO
ARE YOU CURRENTLY ON PROBATION, COMMUNITY SUPERVISION OR PAROLE?……………………... YES NO
HAVE YOU EVER TESTED POSITIVE FOR A CONTROLLED SUBSTANCE IN THE LAST TWO YEARS?... YES NO
HAVE YOU EVER REFUSED A REQUIRED TEST FOR DRUGS OR ALCOHOL IN THE LAST TWO YEARS? YES NO
EXPLAIN ANY YESRESPONSES GIVEN ABOVE AND GIVE DATES OF SAME. CONVICTION INFORMATION SHOULD IN-
CLUDE STATE, COUNTY AND DATE OF OCCURRENCE.
FAILURE TO SIGN WILL RESULT IN AN INCOMPLETE APPLICATION.
Name:
Signature: Date:
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signature
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C I T Y O F D E C A T U R
Notice of Disclosure & Consumer Consent
(Related to Fair Credit Reporting Act)
Consumer Information (Applicant/Employee/Volunteer/Vendor/Solicitor)
The information you provide below will be used solely for the purpose of obtaining consumer reports for employment or business-related purpos-
es. The City of Decatur will not use this information for any reason that violates applicable Federal or State equal employment opportunity laws or
regulations.
Legal Name: Social Security #: Date/Birth:
Home Address: City: ST: ZIP:
Drivers License: Type: Operator Commercial Other Class: A B C Other State/Issue:
Status: o Applicant applying for new position. Name of Position:
o Current employee applying for new position. Name of New Position:
o Volunteer applying for position. Hosting Dept: Name of Position:
o Other Employment or Business-Related Activity. Description:
Disclosure Requirements
In compliance with the Fair Credit Reporting Act (FCRA), the City of Decatur is notifying you as a consumer that in-
formation provided by you on the Citys employment applications or other similar documents may be verified using
consumer reportsprovided by a consumer reporting agency(CRA) for employment purposes or other legitimate
business-related purposes. The City of Decatur has contracted with a number of CRAs to verify certain information
provided by you for employment or business-related purposes. Under FCRA, employment purposesmeans a re-
port used for evaluating a consumer for employment, promotion, reassignment, or retention as an employee.
Business-related purposes includes volunteer applicants, vendors/solicitors, license/permit applicants, or others
performing business-related services related to the City.
As defined in FCRA 603 (d) (1) (A), consumer reportsinclude, but are not limited to, written communications from
CRAs reflecting an applicants financial position, character, general reputation, personal characteristics or mode of
living for employment purposes. Examples of consumer reportsthat the City may use include, but are not limited
to verifications and/or information on the following: motor vehicle records, criminal and civil records, credit reports,
education records, prior employment, and other public documents.
Your employment, continued employment, or affiliation with the City of Decatur may be determined in whole or in
part by the City using data from consumer reports supplied by various CRAs. Pursuant to Section 609 of the FCRA,
you may be entitled to a copy of the consumer reports provided by the CRA.
In compliance with the FCRA, the City of Decatur agrees information obtained through CRAs will not be used in vio-
lation of any applicable Federal or State equal employment opportunity law or regulation.
Consumer Acknowledgement and Consent
I understand and agree that one or more consumer reporting agencies will verify all or part of the information I have
given the City of Decatur in employment applications, telephone conversations, interviews, or by other means during
the application process for employment, volunteer opportunities, licenses/permits, or other similar legitimate busi-
ness-related activities. I understand that this verification may include an inquiry into my credit history, motor vehicle
driving records, criminal and civil records, prior employment (including contacting prior employers), education
(degree, GPA and attendance) as well as other public record information.
I release and hold harmless from all liability any individual or entity, including the City of Decatur and the CRAs it
uses, for requesting or supplying information with respect to my application for employment or other legitimate busi-
ness-related purpose. If employed or accepted by the City, I understand that this document will remain valid
throughout my employment and/or affiliation with the City. I agree that this document constitutes proper, legal notice
of FCRA disclosures and authorizes my consent to perform checks related to my employment or business affiliation
with the City.
I authorize and consent to the release of such information as may be necessary to verify the information I
have provided. I am also aware, and do further consent and authorize the City of Decatur to use this infor-
mation to evaluate my candidacy for employment, my continued employment, or my affiliation with the City
of Decatur.
Printed/Typed Name of Consumer Signature of Consumer Date
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signature
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C I T Y O F D E C A T U R
Equal Employment Opportunity Data Record
DATA RECORD PURPOSE:
As a municipality and recipient of federal funds, the City of Decatur is subject to federal and state laws
requiring equal employment opportunity. In order to monitor compliance with these laws and to assure job
openings reach qualified applicants, we ask all applicants for all positions to provide the following infor-
mation, which will be maintained in a confidential manner to the extent authorized by law. This infor-
mation will be separate from your application and employment-related files and will not be used as the
basis for making employment decisions. Your voluntary participation in obtaining this information is great-
ly appreciated. After completion, please return to the City at the following address as soon as possible:
City of Decatur
Human Resources Department
201 East Walnut ~ P.O. Box 1299
Decatur, Texas 76234
T: 940-393-0205 ~ F: 940-627-1341
APPLICANT INFORMATION:
Full Name:
Last First Middle
Address: City: ST: ZIP:
Todays Date: Gender: Female Male Date of Birth: Age:
POSITION APPLIED FOR:
Job Title: Dept:
ETHNICITY (check only one):
White/Caucasian (non-Hispanic) African American/Black American Indian/Alaskan Native
Hispanic (including persons of Mexican, Puerto Rican, Cuban, South American or other Spanish origin or culture
regardless of Race)
Asian or Pacific Islander Other (please specify)
REFERRAL SOURCES (may check more than one):
CITY RESOURCES: HR Job Posting Board City website Other
NEWSPAPER: Fort Worth Star Telegram Dallas Morning News Wise County Messenger
Other
PROFESSIONAL ORGANIZATION: (please specify)
PERIODICAL/JOURNAL: (please specify):
OTHER: City employee Friend not working at the City Agency TML
Texas Workforce Internet site (please specify):
SIGNATURE:
Printed Name of Applicant Signature of Applicant Date
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signature
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CITY OF DECATUR AT-WILL EMPLOYER
I understand that nothing in this application, or in any prior or subsequent written or oral statement, creates a
contract of employment or any rights in the nature of a contract. I agree and understand that if I am hired by the
City of Decatur my employment will be at-will, for an indefinite period of time, and may be terminated at any
time, with or without cause or notice, at the option of the City of Decatur or myself. I understand that I have the
right to end my employment at any time and that the City of Decatur retains that same right. I also understand
that no one has the authority to enter into any contract, agreement or modification of the foregoing unless such
contract, agreement or modification is in writing and signed by the City Manager.
Signature Date
WRITTEN NOTICE
The applicant will need to sign the application in person if selected to go through the interview process to be
officially accepted for a position.
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signature
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