An Equal Opportunity Employer
The City of Pataskala offers equal employment opportunity to all persons without regard to race, color, age, religion, sex, national origin, disability or
veteran status. No question on this Application is intended to secure information to be used for discriminatory purposes. This Application will
expire after one (1) year. NOTE: This Employment Application will not be considered unless all pages are fully completed.
PERSONAL INFORMATION
NAME: SOCIAL SECURITY NO.:
LAST FIRST M.I.
ADDRESS:
STREET CITY STATE ZIP CODE
FORMER ADDRESS (IF AT CURRENT ADDRESS LESS THAN ONE (1) YEAR):
STREET CITY STATE ZIP CODE
TELEPHONE #: ALTERNATE TELEPHONE #:
HAVE YOU EVER BEEN CONVICTED OF A CRIME, OTHER THAN A MINOR TRAFFIC VIOLATION?
YES NO Note: Checking "Yes" does not automatically disqualify
you from consideration for employment, but will be considered as part of an overall evaluation of your qualifications.
IF YES, DESCRIBE:
REFERRAL SOURCE:
NEWSPAPER AD PLACEMENT OFFICE RADIO POSTING JOB FAIR EMPLOYMENT OFFICE OTHER
EMPLOYMENT DESIRED/AVAILABILITY
DESIRED POSITION: HAVE YOU EVER WORKED OR PREVIOUSLY APPLIED
YES NO
FOR EMPLOYMENT WITH THE CITY OF PATASKALA?
ARE YOU 18 YEARS OR OLDER
YES NO
IF YES, WHEN:
DESIRED STATUS:
FULL-TIME PART-TIME OTHER EXPECTED SALARY:
IF YOU ARE OFFERED AND ACCEPT A JOB, CAN YOU SUBMIT PROOF OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES?
YES NO
TO HELP BETTER MATCH YOUR AVAILABILITY WITH THE POSITION BEING APPLIED FOR, STATE YOUR GENERAL AVAILABILITY:
DAY SUN. MON. TUES. WED. THURS. FRI. SAT.
FROM A.M.
TO P.M.
DO YOU HAVE A CURRENT VALID DRIVER’S LICENSE?
YES NO '2<28+$9($&855(179$/,'&200(5&,$/'5,9(56/,&(16(<(612
EDUCATIONAL BACKGROUND
DO YOU HAVE ANY PROFESSIONAL LICENSES?
YES NO IF YES, TYPE: NO.: EXP.:
TYPE: NO.: EXP.:
ARE YOU CURRENTLY A STUDENT?
YES NO
SCHOOL/LOCATION NO. OF YRS. COMPLETED DEGREE RECEIVED COURSE OF STUDY
HIGH SCHOOL/GED
BUSINESS/ VOCATIONAL
SCHOOL
COLLEGE
GRADUATE SCHOOL
ADDITIONAL SKILLS, TRAINING, QUALIFICATIONS
City of Pataskala, Ohio
621 W. Broad Street, Suite 2B
Pataskala, Ohio 43062
Employment
Application
EMPLOYMENT HISTORY
Please list the last five (5) years of your employment history, starting with your present employer. Attach additional sheets if necessary.
COMPANY NAME, ADDRESS, TELEPHONE NUMBER
DATES OF EMPLOYMENT BEGINNING AND ENDING WAGES
POSITION(S) HELD AND DUTIES PERFORMED
REASON(S) FOR LEAVING
NAME OF SUPERVISOR MAY WE CONTACT? IF NOT, WHY?
COMPANY NAME, ADDRESS, TELEPHONE NUMBER
DATES OF EMPLOYMENT BEGINNING AND ENDING WAGES
POSITION(S) HELD AND DUTIES PERFORMED
REASON(S) FOR LEAVING
NAME OF SUPERVISOR MAY WE CONTACT? IF NOT, WHY?
COMPANY NAME, ADDRESS, TELEPHONE NUMBER
DATES OF EMPLOYMENT BEGINNING AND ENDING WAGES
POSITION(S) HELD AND DUTIES PERFORMED
REASON(S) FOR LEAVING
NAME OF SUPERVISOR MAY WE CONTACT? IF NOT, WHY?
IF YOU HAVE BEEN UNEMPLOYED FOR MORE THAN ONE (1) MONTH, PLEASE INCLUDE AS PART OF YOUR EMPLOYMENT HISTORY.
PROFESSIONAL/CHARACTER REFERENCES
Name/Title Address Tele
p
hone Number Yrs. Ac
q
uainted
PLEASE READ THE FOLLOWING STATEMENTS BELOW. BY SUBMITTING THIS APPLICATION, YOU ARE
ACKNOWLEDGING THAT YOU HAVE READ AND UNDERSTAND THE STATEMENTS BELOW.
I affirm that the information provided by me on this application for employment is true, complete and correct to the best of my knowledge. I understand that any false statement given on this
application for employment may be considered just cause for my immediate dismissal. I authorize investigation of all information related to items listed on this application for employment and
release all persons, schools, companies, corporations and other agencies to provide information concerning my background.
I acknowledge that I, voluntarily and of my own free will, have applied for employment with the City of Pataskala with the understanding that the City may use a variety of screening
procedures to evaluate my qualifications and suitability for appointment. I have been advised that these screening procedures may include, but are not limited to, interviews, criminal record
checks, driving record checks, polygraph examinations, written testing, reference checks, background investigations, psychological evaluations, medical examinations, and drug testing. I
hereby understand that I would not be required to actually participate in a psychological evaluation, medical examination, and drug testing until after I have reached a conditional offer of
employment. I also acknowledge that I may also be subject to other screening procedures, not specifically listed above. I further acknowledge that any such screening procedures, as
reasonably required by the City of Pataskala, are a prerequisite to my appointment to a position with the City of Pataskala.
I further acknowledge that the City of Pataskala cannot guarantee the confidentiality of the results of, or information obtained through, the aforementioned screening procedures. Rulings of the
Ohio Supreme Court relative to the Public Records Act indicate that, with certain enumerated exceptions, records maintained by a governmental entity are a matter of public record and, should
a proper request be made by a member of the public for such records, the governmental entity would be required to make such records available to that member of the public within a
reasonable period of time. Employment related documents, with the exception of medical records, maintained by the City of Pataskala related to the aforementioned screening procedures do
not appear to fall within the enumerated exceptions.
I further understand that the City of Pataskala has a commitment to maintain an alcohol and drug free workplace and unless prohibited by law, I may be required to submit to a drug test for the
illegal use of controlled substances if I am offered a position. The illegal use of controlled substances will result in disqualification from consideration for employment and any offer of
employment withdrawn. If I am employed, I acknowledge that I may be required to submit to alcohol and/or drug testing under certain circumstances.
I understand that if I am employed, I will be an employee at-will, that my employment is for no definite period of time and that I may resign or be terminated at any time without prior notice or
cause and the terms and conditions of my employment can be changed at any time.
___________________________________________
DATE SIGNATURE
CHECK HERE IF RESUME IS ATTACHED:
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