Fillable APP SC2018

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APP SC2018

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Personnel Board
INSTRUCTIONS
IMPORTANT INSTRUCTIONS ABOUT THIS FILLABLE FORM!
Please be advised that while the Application Form is in a fillable PDF format, it is NOT
currently transmittable from the URL website. Sending a filled application form directly from
the URL location (see below) will result in the delivery of a BLANK/EMPTY FORM!
PLEASE DOWNLOAD, PRINT, SIGN AND RETURN COMPLETED APPLICATION FORM TO
Human Resources Department
Mail: P. O. Box 1984, Decatur, AL 35602
In person: City Hall Tower-2nd Floor, 402 Lee Street, NE, Decatur, AL 35602
Email: Downloaded, completed & signed form to employment@decatur-al.gov
Do not send filled from
directly from URL!
City of Decatur Employment Application – Rev 01/2016 Page 1
Personnel Board
APPLICATION FOR EMPLOYMENT
City Of Decatur
P O Box 1984, Decatur, AL 35602
employment@decatur-al.gov
www.decaturalabamausa.com
An Equal Opportunity Employer
Date of Applicatio
n
Position Applied For
HR DEPT USE
ONLY
Accepted
Rejected
Citizenship
Education
How did you hear about this job posting?
Please be specific.
Newspaper____________________ Job Board_________________
City Employee _________________ Other_____________________
Experience
Residency
Other
Last Name:
First Name:
Middle Initial
Social Security Number
Present Mailing/Street Address
City
County
State
Zip Code
City
County
State
Zip Code
Home Telephone No. (Area Code) Number Cell Phone No. (Area Code) Number
E-mail Address:
Previous Addresses for past (5) years:
Are you 18 years of age or older?
Yes No
Have you ever been convicted of a
felony? Yes No
If yes, explain
Are you a US Citizen? Yes No
If no, are you legally authorized to work in the US and can you
comply with the following requirement*?
Yes No
*To comply with the Immigration Reform and Control Act of 1986, if you are hired you will be required to provide documents to establish your identity and your
authorization to be employed in the United States. Such documents will be
required within the first three (3) business days following your hire; or upon your
first day of work if your employment period will be less than three (3) days.
Do you have a current commercial driver’s license
(CDL)?
Yes No
If yes, please attach a copy
Do you have a valid driver’s license?
State______ License No.:_________________
Yes No
Have you ever worked for the City of Decatur or other
Alabama government entity?
Yes
No
Have you ever been disciplined or discharged for
making threats or any incident involving
violence?
Yes No
If yes, when:
Position:
Department:
Have you ever been disciplined, disc
harged for
forced to resign for any other reason? If yes,
please explain:___________________________
Yes No
If yes, reason for leaving:
Do you have relatives employed
with the city of Decatur?
Yes No If yes, please provide name and
relationship:
Have you applied for employment with
the City of Decatur before?
Yes No
If yes, when:
If hired, when can
you start?
Desired Salary?
High School Name / Address
City
County
State
Zip Code
Graduated
Type of Diploma, Degree, Certificate or Equivalency Diploma
Yes No
Secondary School Name / Address
City
County
State
Zip Code
Type of School (Check One)
Major Field of Study
Graduated
Yes No
Degree/Certificate
Type
(if no, total credits)
Academic Standing (Overall GPA out of
possible total (e.g. 3.2/4.0) or average grade
(e.g. B+ or 85%):
Vocational Schools, Technical
Institutes, Community, Military
Schools, and junior colleges
All Other
Colleges/Universities
Secondary School Name / Address
City
County
State
Zip Code
Major Field of Study:
Graduated: Yes No
Degree/Certificate Type (if no, total
credits)
Type of School (Check One)
Academic Standing (Overall GPA out of possible total (e.g. 3.2/4.0) or average
grade (e.g. B+ or 85%):
Vocational Schools, Technical Institutes,
Community, Military Schools, and junior colleges
All Other
Colleges/Universities
List other relevant technical education, training, computer skills or experience you would like City of Decatur to consider relevant to your job qualifications:
List academic honors, scholarships, fellowships; memberships in academic honorary societies; participation in/offices held in job related activities.
School Crossing Guard
Permanent Mailing Address (if different)
*Eligible candidates may
receive notification of the
next step in the
employment process via
EMAIL. Where email
information is not provided,
information will be sent via
U.S. Mail and the City is not
responsible for Postal
Service delays.
City of Decatur Employment Application – Rev 01/2016 Page 2 of 3
EMPLOYMENT RECORD
Please list all employment for the past ten (10) year
s with most recent employment first; be sure to include complete
mailing address. For additional work history or other experience, skills or qualifications, please attach using
separate piece of paper.
Employer: LENGTH OF EMPLOYMENT
Address: FROM:mm/yyyy
TO: mm/yyyy
Telephone Position
Supervisor Supervisor’s Position Hours Per Week:
PRINCIPAL RESPONSIBILITIES:
Starting Salary:
Ending Salary:
Bonus:
REASON FOR LEAVING:
May We Contact Your Current Employer?
YES NO
Employer: LENGTH OF EMPLOYMENT
Address: FROM:mm/yyyy
TO: mm/yyyy
Telephone Position
Supervisor Supervisor’s Position Hours Per Week:
PRINCIPAL RESPONSIBILITIES:
Starting Salary:
Ending Salary:
Bonus:
REASON FOR LEAVING:
May We Contact Your Past Employer?
YES NO
Employer: LENGTH OF EMPLOYMENT
Address: FROM:mm/yyyy
TO:mm/yyyy
Telephone Position
Supervisor Supervisor’s Position Hours Per Week:
PRINCIPAL RESPONSIBILITIES:
Starting Salary:
Ending Salary:
Bonus:
REASON FOR LEAVING:
May We Contact Your Past Employer?
YES NO
Employer: LENGTH OF EMPLOYMENT
Address: FROM:mm/yyyy TO:mm/yyyy
Telephone Position
Supervisor Supervisor’s Position Hours Per Week:
PRINCIPAL RESPONSIBILITIES:
Starting Salary:
Ending Salary:
Bonus:
REASON FOR LEAVING:
May We Contact Your Past Employer?
YES NO
City of Decatur Employment Application – Rev 01/2016 Page 3 of 3
Personnel Board
Applicant Consent and Release Form
REFERENCES
Work related references (Do not include relatives)
CHECK ONE
Occupational Reference
Personal Reference (only if no Work Reference)
NAME
OCCUPATION
ADDRESS (STREET, CITY, STATE, ZIP CODE)
TELEPHONE
EMAIL
CHECK ONE
Occupational Reference
Personal
Reference (only if no Work Reference)
NAME
OCCUPATION
ADDRESS (STREET, CITY, STATE, ZIP CODE)
TELEPHONE
EMAIL
CHECK ONE
Occupational Reference
Personal Reference (only if no Work Reference)
NAME
OCCUPATION
ADDRESS (STREET, CITY, STATE, ZIP CODE)
TELEPHONE
EMAIL
CONSENT AND RELEASE
- PLEASE READ CAREFULLY BEFORE SIGNING.
I hereby certify that all statements made in this application or interview(s) are true and correct to the best of my knowledge and belief. I understand and
agree that any false or misleading information or omission of facts given in my application or interview(s) may be justification for refusal to hire or
termination of employment.
I hereby agree and consent to taking physical or other examinations when requested to do so by the City of Decatur. I understand that City of Decatur
employees or applicants for employment are subject to testing for substance and drug use, including marijuana.
I further understand that an investigative report may be made as to my character and general reputation. I authorize all past employers, schools, persons
and organizations including, but not limited to, law enforcement agencies and licensing agencies, having relevant information or knowledge to provide it to
The City of Decatur or its duly authorized representative for its use in deciding whether or not to offer me employment and specifically waive any required
written notification. I hereby release employers, schools, persons and organizations from all liability in responding to inquiries in connection with my
application. Upon written request by me, within a reasonable period of time, the City of Decatur will make available to me the nature and scope of all
reports of every type obtained.
I understand that nothing contained in this employment application or in the granting of an examination or an interview is intended to create an employment
contract between the City of Decatur and me for either employment or for the providing of a benefit. If an employment relationship is established, I
understand and acknowledge that it is of an “at will” nature, which means that my employment can be terminated at any time, with or without cause, at the
option of either the City of Decatur or myself.
An offer of employment with the City of Decatur is contingent on my providing sufficient documentation necessary to establish my identity to work in the
United States. I also understand that a job offer is contingent upon successfully passing a drug and alcohol test and criminal background check. Other
screenings may be conducted depending on position (i.e. a credit check may be completed for positions holding financial responsibility.). Appropriate
notification and paperwork will be provided.
In signing this form, I certify that I understand all the questions and statements in this application.
*By providing an email address on this form, I consent to receive electronic communications regarding application status, examination schedule
confirmations, etc. and as applicable. I understand that if no email address is provided, all communications will be sent via U.S. Mail and the City is not
responsible for Postal Service delivery delays that may impact my eligibility to be considered for employment.
APPLICANT'S SIGNATURE
DATE
We are an Equal Opportunity Employer.
We do not discriminate on the basis of race, religion, color, sex, age, national origin or disability.
Completed employment application, with resume, must be returned to the City of Decatur Human Resources Department located at City Hall
Tower, 402 Lee Street NE, Decatur, AL 35602; mailed to P. O. Box 1984, Decatur, AL 35602; or emailed to employment@decatur-al.gov.
The Human Resources Department may be contacted at (256) 341-4890.
AN EQUAL OPPORTUNITY EMPLOYER
VOLUNTARY Self-Identification / Equal Employment Opportunity
We are an Equal Opportunity Employer and do not discriminate on the basis of ethnicity, color, religion,
gender, gender identity, age, national origin, disability, veteran status, sexual orientation or any other
classification protected by Federal, State or local law. The information below will be used only in the
compilation of data for Equal Opportunity reporting. Completion of this form is VOLUNTARY and in no way
affects the decision regarding your application for employment. This form is confidential and will be maintained separately
from your application form. Applicants requiring reasonable accommodation for any part of the application and hiring
process should contact the Human Resources Department as noted on each vacancy announcement. Determinations on
requests for reasonable accommodation are made by the Human Resources Director and will be made on a case-by-case
basis.
VOLUNTARY Applicant Information
Last Name:
Date:
First Name:
Middle Initial:
Position sought: (List only one.)
Sex: (Please Check One) Male Female
EEO ETHNICITY CATEGORY (Please check one of the descriptions below corresponding to the ethnic group with
which you most identify.)
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original
peoples of North and South America (including Central America), and who maintain tribal affiliation or community
attachment
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial
groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa
Two or More Races - All persons who identify with more than one of the six races
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
Islander
Hispanic or Latino
White
VETERAN STATUS (Please check if it describes your veteran status.)
Are you a veteran? Yes No
IMPORTANT NOTICE TO APPLICANT:
PLEASE READ THIS NOTICE AND CONSENT
FORM CAREFULLY
BEFORE SIGNING. A C O P Y O F T H I S F O R M WILL BE PROVIDED AT ANY TIME UPON REQUEST
NOTICE AND CONSENT CONCERNING CONSUMER REPORTS FOR EMPLOYMENT APPLICATIONS AND
EMPLOYMENT PURPOSES
This form, which you should read carefully, has been provided to you because the City of
Decatur may request consumer
reports or investigative consumer reports in connection with your application for employment or during the course of your
employment with the City of Decatur, if any, for other employment-related purposes.
The City of Decatur recognizes the importance of maintaining a safe workplace with honest, trustworthy, qualified, reliable
and non-violent employees who do not present a
risk of serious harm to their co-employees or others. For the benefit of all
employees and
the City, in furthering these interests and enforcing the City's policies, the City may
perform applicant
background checks and employee investigations. These background
checks and investigations may be performed by the
City in whole or in part, at the City's
discretion.
The C
ity's applicant background checks and employee investigations may also include the use of consumer reporting agencies
to gather and report information to the City in the
form of consumer or investigative consumer reports regulated by federal
law. Such reports, if obtained will be prepared by consumer reporting agencies and may contain information concerning your
credit standing or worthiness, credit capacity, character, general reputation, personal characteristics, or mode of living.
Federal law defines a "consumer reporting agency" as any person (or entity) which for monetary fees, dues, or
on a cooperative
nonprofit basis, regularly engages in whole or in part in the practice of assembling or evaluating consumer credit information
on consumers for the purpose of furnishing reports to third parties. The City is not a consumer reporting agency.
The type
s of reports that may be requested from consumer reporting agencies under this
policy, include, but are not limited
to, credit reports, criminal records checks, court records checks, driving records, and/or summaries of educational and
employment records and histories. The information contained in these reports may be obtained by a
consumer reporting agency
from public record sources or through personal interviews with your co-workers, neighbors, friends, associates, current or
former employers, or other personal acquaintances. Any information contained in such reports may be taken
into consideration
in evaluating your suitability for employment, promotion, reassignment or retention as an employee.
If the City r
equests an investigative consumer report to be performed by a consumer
reporting agency,
as
defined by federal law, you
will receive a notice indicating that the
report has been requested no later than three days after the request is made to the agency.
This
additional notice, if issued, will provide you with further information pertaining to
federal law governing investigative consumer reports.
You will not receive such a notice
if the investigation is performed by the City or a person or entity other than a consumer
reporting
agency.
If any adverse decision is made with regard to your application for employment or
subsequent employment with the City, if any, based
entirely or in part on the information
contained a consumer report or investigative consumer report prepared by a consumer
reporting
agency, you will be notified and given a copy of the report,
as
well as a
summary of your applicable rights. If you have every filed for
bankruptcy, no
employment decision will be based solely on this information.
Your co
nsent is required by law before the City may obtain a consumer report or
investigative consumer report from a consumer
reporting agency pertaining to your
application for employment and thereafter, during the course of your employment, if any,
in the
City's discretion. Your signature on the enclosed Consent Statement indicates that
you have carefully read and understand that the City
may request and review consumer
reports and investigative consumer reports regarding you, consistent with this policy,
both in
connection with your application for employment and during the course of your
employment, if any, and that you consent to the
release of such consumer reports or
investigative consumer reports to the City for employment purposes, including any future
decisions
concerning your, employment, promotion, reassignment or retention as an
employee of the City of Decatur. Your signature additionally
reflects your understanding
that such consent will remain in effect indefinitely until you revoke it (cancel it) in
writing.
Limit
ations on the City's ability to conduct lawful investigations of applicants and
employees for purposes of promoting a safe
workplace and otherwise maintaining an
honest, trustworthy, qualified, reliable, and non-violent workforce, are not acceptable.
The
City of Decatur employees are consequently expected to maintain their consent to
the City's potential use of consumer and investigative
consumer reports in keeping with
this policy and are otherwise expected to cooperate fully with the City's lawful efforts to
obtain such
information. Refusal to consent to a consumer report or investigative
consumer report as required by this notice and the City's
policies, or any other attempt to
interfere or failure to cooperate with the City's lawful investigation of any applicant or
employee, may
result in rejection of any application, withdrawal of an offer of
employment or discipline, up to and including termination from
employment.
Personnel Board
Employment Application Attachment
Applicant Consent and Release Statement
_______________
__________________ ________________________________________
Name of Applicant (Printed) Position Applied For
I
have
carefully
read
and
understand this
notice
and
consent
form
and,
by
my
signature
below,
consent
to
the
release
of
consumer
or
investigative
consumer reports,
as
defined
above,
to
the
City
of
Decatur
in
conjunction
with my
application
for
employment. I further
understand that
this
consent
will apply
during
the
course of
my
employment with
the
City
of
Decatur,
should
I
obtain
such
employment, and that
such
consent
will
remain
in
effect
until
revoked in
a
written document
signed
by
me
.
In
the
event
that I wish r
efus
e
or
revoke
my consent
at
any
time, I
understand
that I m
ay
do
so
by
sending
a signed
letter
or
statement
to
the
City
of
Decatur,
indicating
that
revoke
my
consent
to
the
City's
obtaining
consumer
reports
or
investigative
reports
about
me
for
employment
purposes
.
I
further
understand
that
any
and
all
information
contained in my
job
application
or
otherwise
dis
closed
to
the
City
of
Decatur
by
me may
be
utilized for
the purpose
of
obtaining
the
consumer
reports
or
investigative
consumer
reports
requested
by
the City
of
Decatur
and
confirm
that
all
such
information
is
true
and
correct.
I
understand
and
acknowledge
that
nothing in
this
Notice
and
Consent
is
intended
to
be
,
or
is,
an
offer
of
employment
or
a
promise
of
continued
employment
.
If
employed
by
the City
of
Decatur,
my
employment
wi ll
not
be
for
a
specified
period
of
time
and
can
be
terminated at any time pursuant
to the provisions of the Merit System Rules of the City of
Decatur.
Applicant Signature
Date
Signed Consent form should be returned with completed employment application and resume to City of
Decatur Human Resources Department, 402 Lee Street NE, Decatur, AL 35602; mailed to P. O Box 1984,
Decatur, AL 35602; or emailed to employment@decatur-al.gov.
The Human Resources Department c
an be reached at (256) 341-4890.
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APP SC2018

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Completed 15 July 2020

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