Fillable An Equal Opportunity Employer- All qualified applicants will (City of Belen)

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An Equal Opportunity Employer- All qualified applicants will (City of Belen)

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BROWSE CITY OF BELEN (NM) FORMS

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CITY OF BELEN

100 S. Main St.

Belen, New Mexico 87002

HR: 505.966.2742

cobhr@belen-nm.gov

Employment Application ☐ General ☐ Police ☐ Fire

An Equal Opportunity Employer- All qualified applicants will receive consideration for

employment without regard to race, color, religion, sex, national origin, disability status,

protected veteran status, or any other characteristic protected by law.

Applicant Information

Incomplete information could disqualify you from further consideration. Please complete all fields.

Full Name: ________________________________________________________ Date: _______________________

Last First M.I.

Address: ______________________________________________________________________________________

Street Address Apartment/Unit #

______________________________________________________________________________________

City State ZIP Code

Phone: ____________________________________ Email: _____________________________________________

Position Applied for: _________________________________ Hourly Wage Desired? ___________________

Are you eligible to work in the US? ____ YES ____ NO

Have you previously worked for the City of Belen ____YES ___NO

Are you at least 18 years or older? ____ YES ____ NO (If no, you may be required to provide authorization to

work.)

Do you know of any relatives that previously worked for the City of Belen? ______YES _______NO

If yes, who?

____________________________________________________________________________________________

Have you ever been terminated from employment or asked to resign by an employer? ____ YES ____ NO

If yes, please provide company name and details

_____________________________________________________________________________________________

Can you work any shift? ____ YES ____ NO Can you work overtime, including weekends? ____ YES ____ NO

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable

accommodation? ____ YES ____ NO

Date you are available to start? ____________________________ Are you currently employed? ____ YES ____ NO

If yes, may we contact your present employer? ____ YES ____ NO

CITY OF BELEN

100 S. Main St.

Belen, New Mexico 87002

HR: 505.966.2742

cobhr@belen-nm.gov

Referral Source

How did you hear about us? ____ Walk-In ____ Advertisement ____ Referral ____ Other

If other, please specify__________________________________________________________________

Previous Employment

Include your last ten (10) years of employment history, including periods of unemployment, starting with the most

recent and working backwards in time. Incomplete information could disqualify you from further consideration.

Employer _____________________________Job Title_________________________________________

Hourly Rate/Salary ________________________

Address______________________________________________________________________________

Reason for leaving __________________________________Telephone__________________________

Supervisor Name_______________________ Dates Employed________________________________

Work Performed ___________________

_______________________________________________

______________________________________________________________________________

Previous Employment

Employer ___________________Job Title____________________________________________

Hourly Rate/Salary______________________

Address_______________________________________________________________________

Reason for

leaving__________________________________Telephone_____________________________

Supervisor Name__________________ Dates Employed ________________________________

Work

Performed_____________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

CITY OF BELEN

100 S. Main St.

Belen, New Mexico 87002

HR: 505.966.2742

cobhr@belen-nm.gov

Previous Employment

Employer ___________________________Job Title____________________________________

Hourly Rate/Salary______________________

Address_______________________________________________________________________

Reason for

leaving_________________________________Telephone______________________________

Supervisor Name____________________________ Dates Employed ___________________

Work

Performed_____________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

Previous Employment

Employer __________________________Job Title_____________________________________

Hourly Rate/Salary______________________

Address_______________________________________________________________________

Reason for

leaving_____________________________________Telephone__________________________

Supervisor Name_______________________ Dates Employed ___________________________

Work

Performed_____________________________________________________________________

______________________________________________________________________________

CITY OF BELEN

100 S. Main St.

Belen, New Mexico 87002

HR: 505.966.2742

cobhr@belen-nm.gov

Previous Employment

Employer ________________________________________Job Title_______________________

Hourly Rate/Salary______________________

Address______________________________________________________________________

Reason for

leaving_____________________________________Telephone__________________________

Supervisor Name____________________________ Dates Employed______________________

Work

Performed_____________________________________________________________________

______________________________________________________________________________

Education

Education Name and Location No. of yrs. Attended Degree Received Subject/Major

Of school

High School ____________________________________________________________________

College or

University______________________________________________________________________

Trade, Business

Or Correspondence

School ________________________________________________________________________

Do you have any special skills, experience and/or training that would enhance your ability to

perform the position applied for? If yes, explain.

______________________________________________________________________________

CITY OF BELEN

100 S. Main St.

Belen, New Mexico 87002

HR: 505.966.2742

cobhr@belen-nm.gov

References

Please list three professional references.

Full Name: __________________________________Relationship: _______________________

Company: ________________________________Phone: _______________________________

Address: ______________________________________________________________________

Full Name: ___________________________________Relationship: ______________________

Company: _________________________________ Phone: _____________________________

Address: ______________________________________________________________________

Full Name: ___________________________Relationship: ______________________________

Company: _____________________________________Phone: __________________________

Address: ______________________________________________________________________

Applicants Statement

I hereby affirm that the information provided on this application (and accompanying resume, if any) is

true and complete to the best of my knowledge. I also agree that falsified information or significant

omissions may disqualify me from further consideration for employment and may be considered

justification for dismissal if discovered at a later date.

I authorized all persons listed above (and on the accompanying resume, if any) to give the City of Belen

any and all information concerning my previous employment and education and any pertinent

information they may have, personal or otherwise, and release all parties, such persons and the City of

Belen, from liability for any damage that may result from furnishing said information to the City of

Belen.

I understand and agree that I may be required to take a drug screening test. I hereby give my voluntary

consent for a urine sample to be collected from me and submitted for testing. I also consent to the

release of test results to the City of Belen for its use. I understand that any positive drug test result may

preclude my employment.

Signature: ___________________________________Date: _____________________________

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