1/17/2020
City of Manchester
Employment Application Form
14318 Manchester Rd.
Manchester, MO 63011
(636) 227-1385 - Telephone
(636) 207-2824 - Fax
PLEASE PRINT CLEARLY
Date:_____________________________
If yes, branch of service _______________________________
PREVIOUS MILITARY SERVICE:
Are you a veteran?
Dates of Service:
Entered __________________ Discharge ________________________
EDUCATIONAL BACKGROUND: INCLUDE ALL FORMAL TRAINING PROGRAMS
AND ACADEMIC DEGREES. ATTACH ADDITIONAL SHEET IF NECESSARY.
NAME OF SCHOOL
OR PROGRAM
ADDRESS CREDITS
COMPLETED
DEGREE
EARNED
COMPLETED/
GRADUATE?
Name_________________________________________________________________________
Address _______________________________________________________________________
Telephone ____________________________________________________________________
Email Address ________________________________________________________________
Position Applying for _____________________________ FULL-TIME PART-TIME
SEASONAL
How soon are you available to start work? _______________________________________________
Are you eligible to work in the United States? Yes No
Are you over the age of 18? Yes No
If no, hire is subject to verification that you are of minimum legal age.
List any additional training, special qualifications, skills or honors you would like considered:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
WORK EXPERIENCE: BEGINNING WITH YOUR MOST RECENT EMPLOYMENT, LIST A COMPLETE
STATEMENT OF YOUR WORK HISTORY. ATTACH ADDITIONAL SHEETS IF NECESSARY
1.Position held_______________________________
Salary____________________________
Dates of employment from:_________________________ to:_________________________________
Employer______________________________________________
Address______________________________________________________________________________
Supervisor's Name________________________________Telephone__________________________
May we contact your previous supervisor? Yes No
Duties/Responsibilities_________________________________________________________________
_____________________________________________________________________________________
Reason for Leaving____________________________________________________________________
2. Position held_______________________________ Salary____________________________
Dates of employment from:_________________________ to:______________________________
Employer______________________________________________
Address_____________________________________________________________________________
Supervisor's Name________________________________Telephone__________________________
May we contact your previous supervisor? Yes No
Duties/Responsibilities________________________________________________________________
____________________________________________________________________________________
Reason for Leaving___________________________________________________________________
3. Position held_______________________________ Salary____________________________
Dates of employment from:_________________________ to:______________________________
Employer______________________________________________
Address______________________________________________________________________________
Supervisor's Name________________________________Telephone__________________________
May we contact your previous supervisor? Yes No
Duties/Responsibilities_________________________________________________________________
_____________________________________________________________________________________
Reason for Leaving____________________________________________________________________
1. Name_____________________________________________________________________________
Address ___________________________________________________________________________
Email Address______________________________________________________________________
Telephone______________________________________________
Relationship____________________________________________
How long have you known this person?_____________________
2. Name_____________________________________________________________________________
Address ___________________________________________________________________________
Email Address______________________________________________________________________
Telephone______________________________________________
Relationship____________________________________________
How long have you known this person?_____________________
3. Name_____________________________________________________________________________
Address ___________________________________________________________________________
Email Address______________________________________________________________________
Telephone______________________________________________
Relationship____________________________________________
How long have you known this person?_____________________
REFERENCES: List the following information for at least three references who may be contacted
concerning your work history and background. DO NOT INCLUDE RELATIVES
Do you have any commitments which may restrict your ability to perform your job duties?
Yes No
If yes, provide details:____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you ever been discharged or forced to resign from a position? Yes No
If yes, provide details including the name of the employer and the reason for the action taken:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
City policy requires an applicant, when a bona fide job offer has been made, to pass a physical examination (at the City’s
expense) and be certified by the City’s physician as fit to perform the duties of the position. The pre-employment
examination for candidates includes a drug screen. Failure of the applicant to consent to these inquiries and tests, and
depending on the position, a credit check and background check, and skill and other applicable tests, will disqualify the
applicant from present and future employment consideration by the City.
Federal law requires that the City hire only United States citizens and lawfully authorized alien workers. If you are
selected for a position with the City of Creve Coeur, you will be required to comply with the requirements of the
Immigration and Naturalization Act of 1986. This law requires you to present documentation of your identity and eligibility
to work in the US and to complete a federal I-9 form. This form must be completed on the first day of employment for all
employees.
It is the policy of the City of Manchester not to discriminate on the basis of race, color, religion, national origin, ancestry,
sex, gender, gender identity, sexual orientation, age, disability or familial status, or other status protected by law except
where specific age or physical requirements constitute a bona fide occupational qualification. The job duties will be
reviewed with you to determine your ability to perform the essential functions of the position.
CERTIFICATION OF THE APPLICANT – SEE ALSO SEPARATE SHEET ATTACHED. READ CAREFULLY BEFORE
SIGNING.
I certify that all the answers and statements herein contained are true to the best of my knowledge and belief. I
understand that any misstatement of material facts, or omission of any material facts, will subject me to possible
disqualification or dismissal.
SIGNATURE OF APPLICANT:____________________________________Date:_____________________
1/17/2020
PLEASE READ CAREFULLY BEFORE SIGNING
THIS SECTION TO BE COMPLETED ONLY BY APPLICANTS FOR POSITIONS WHICH
REQUIRE DRIVING ON THE JOB. A DRIVING RECORD CHECK WILL BE PERFORMED AS A
CONDITION OF ANY JOB OFFER TO SUCH APPLICANTS.
License no._______________________
State of Issue_______________
Class of license________________________
Restrictions___________________________
Has your license ever been suspended or revoked? Yes No If yes, on a separate sheet list the
details for each occurrence including: the offense, date, charge, place, court and action taken.
Have you ever been employed by the City of Manchester? Yes No
If yes, when? ________________________________
Do you have any relatives now employed by the City of Manchester? Yes No
If yes, list names and his/her relationship to you:______________________________________________
________________________________________________________________________________________
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14318 Manchester Road Manchester, MO 63011 phone: (636) 227-1385 fax: (636) 207-2824
CERTIFIC
ATE OF APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
(Read carefully before signing)
I, (p
rint full name) ________________________________, hereby certify that all statements made on or
in connection with this application are true and complete to the best of my knowledge and belief. I
understand and agree that any mis-statements or omission of material facts will cause forfeiture on my
part of all rights to employment with the City of Manchester, Missouri.
I hereb
y authorize all law enforcement agencies, the Veterans Administration, U.S. Army, U.S. Navy, U.S.
Air Force, all military agencies, all federal, state, or local government agencies, state and federal tax
bureaus, credit bureaus, schools and universities, to furnish the holder of this release with all and any
available information regarding me in order that he may determine my suitability for employment.
I authorize the holder of this release to make inquiry of my present and past employers regarding my
character, integrity, and reputation. I authorize the release of any and all information regarding my
employment, credit, or any other information, whether personal or otherwise, that may or may not be
in their records, and release said company or person from all liability for any damage whatsoever that
may issue from furnishing such information to the holder of this release.
A photostatic copy of this authorization will be considered as effective and valid as the original.
Date
Signature of Applicant
Driver’s License#___________________________________
Social Security #___________________________________
Date of Birth ______________________________________
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