Fill - Free fillable A P L (City of Decatur) PDF form

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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 City’s 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 City’s 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-OFF” STATUS & 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 “X” THROUGH 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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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 City’s 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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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 “YES” RESPONSES 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

EMPLOYER’S 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 “YES” RESPONSES 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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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:

Driver’s 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 City’s employment applications or other similar documents may be verified using

“consumer reports” provided 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 CRA’s to verify certain information

provided by you for employment or business-related purposes. Under FCRA, “employment purposes” means 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 reports” include, but are not limited to, written communications from

CRA’s reflecting an applicant’s financial position, character, general reputation, personal characteristics or mode of

living for employment purposes. Examples of “consumer reports” that 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 CRA’s. 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 CRA’s 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 CRA’s 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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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:

Today’s 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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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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