APPLICATION FOR
EMPLOYMENT
APPLICANT INFORMATION (If additional space is needed, please feel free to use the bottom of the 3
rd
page or use an attachment.)
Last
Name
First M.I. Date
Street
Address
Apartment/Unit #
City ST Zip Phone E-mail
Social Security No. When are you available for work?
Are you looking for Full Time Part Time Temp Work
Position Applied for
Are you authorized to work in the U.S.? YES NO If no, explain
Have you ever applied with us before? YES NO If so, when? What position?
Have you ever been arrested for a
serious crime?
YES
NO If yes, explain
Do you have a motor vehicle license? YES NO State Lic. # Type
Has your motor vehicle license ever
been sus
p
ended?
YES
NO If yes, explain
Are you currently employed? YES NO If so, can we contact your present employer? Yes No
Are you physically or otherwise able to perform the duties required of the job for which you are applying? Yes No
Are you willing to submit to a physical exam and/or drug test? Yes No
EDUCATION
High School
Address
From To Did you graduate?
YES
NO
Degree
College
Address
From To Did you graduate?
YES
NO
Degree
Other
Address
From To Did you graduate?
YES
NO
Degree
REFERENCES
Please list three professional references.
Full Name Relationship
Company Phone ( )
Address
Page 1 of 3 Rev. 8/15/11
REFERENCES CONTINUED
Full Name Relationship
Company Phone ( )
Address
Full Name Relationship
Company Phone ( )
Address
PREVIOUS EMPLOYMENT
Company Phone ( )
Address Supervisor
Job Title
Starting
Wage
$ per Ending Wage $ per
Responsibilities
From To
Reason for
Leaving
May we contact your previous supervisor for a reference? YES NO
Company Phone ( )
Address Supervisor
Job Title
Starting
Wage
$ per Ending Wage $ per
Responsibilities
From To
Reason for
Leaving
May we contact your previous supervisor for a reference? YES NO
Company Phone ( )
Address Supervisor
Job Title
Starting
Wage
$ per Ending Wage $ per
Responsibilities
From To
Reason for
Leaving
May we contact your previous supervisor for a reference? YES NO
MILITARY SERVICE
Branch From To
Rank at Discharge Type of Discharge
If other than honorable, explain
Explain any job related training while in the military
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Page 3 of 3 Rev. 8/15/11
DISCLAIMER, CERTIFICATION, AUTHORIZATION OF RELEASE, AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment
decision, including conducting a background investigation, contacting past employers (except those specifically excluded), and contacting
government agencies. I agree to fully cooperate in the Town of Stratham’s background investigation, and to sign any waivers or releases
that may be necessary to obtain access to relevant information. In the event that any former employer or federal, state, or local
governmental agency will not release reference information or criminal history information directly to the employer, I agree to personally
request such information to the extent permitted by law.
I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the Town of Stratham is
of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with
or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by
conduct unless such change is specifically acknowledged in writing by the Board of Selectmen of the Town of Stratham.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my
termination. I also understand that I am required to abide by all rules and regulations of the Employer.
Signature: Date:
The Town of Stratham considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or
veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.
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