Fillable Application For Employment Revised 11 25 19

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Application For Employment Revised 11 25 19

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Revised November 2019
CITY OF GROTON APPLICATION FOR EMPLOYMENT
PLEASE NOTE: Applications for employment must be completed in full and can be submitted on line
provided the deadline is met. Attaching a resume does not relieve the applicant of this requirement.
It is the City of Groton's policy to comply with all the laws, statutes and regulations concerning equal employment
opportunities and affirmative action. We strongly encourage women, minorities, individuals with disabilities and
veterans to apply to all of our job openings. We are an equal opportunity employer and all qualified applicants will
receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity
or national origin, age, disability status, genetic information and testing, family and medical leave, protected veteran
status or any other characteristic protected by law. We prohibit retaliation against individuals who bring forth any
complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation
of any complaint or otherwise oppose discrimination.
DATE:
PERSONAL INFORMATION
NAME
Last First Middle Name
PRESENT ADDRESS:
Street Number and Name Apartment #
City State Zip Code
PHONE NUMBER:
Home Phone Cell Phone Email address
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE USA? YES NO
ARE YOU OVER THE AGE OF 18? YES NO
POSITION APPLIED FOR*:
*Please note exact title of position(s) you are applying for.
DATE AVAILABLE TO START WORK: WAGE DESIRED: ____________________________
Revised November 2019
List the names of any and all relatives (blood or otherwise) who currently work for the City of Groton. If you
know the title of the position held by your relative, list the position. If it does not apply, enter N/A in the block
below name of relative.
NAME OF RELATIVE RELATIONSHIP (MOTHER, FATHER, SISTER, COUSIN, ETC.) POSITION HELD
______________________________ _________________________________________________________ ____________________
______________________________ _________________________________________________________ ____________________
DO YOU SPEAK, READ OR WRITE ANOTHER LANGUAGE OTHER THAN ENGLISH? YES NO
PLEASE SPECIFY:__________________________________________________________________________________________________
EMPLOYMENT INFORMATION
ARE YOU PHYSICALLY AND MENTALLY ABLE TO PERFORM THE JOB APPLIED FOR? YES NO
(If NO, is there any accommodation that would allow you to perform this job?) YES NO
DO YOU HAVE ANY OBJECTION TO WORKING OVERTIME WITHOUT PRIOR NOTICE? YES NO
CAN YOU TRAVEL OUT OF STATE IF REQUIRED BY THIS POSITION? YES NO
LICENSE INFORMATION
DO YOU POSSESS A VALID DRIVER’S LICENSE? YES NO In what state? __________
DO YOU POSSESS A VALID COMMERCIAL DRIVER’S LICENSE? YES NO Class A or B? __________
DO YOU POSSESS ANOTHER OPERATOR’S LICENSE? YES NO
If yes, please specify the class and/or endorsement: ________________________________________________________________________
HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? YES NO
Revised November 2019
EMPLOYMENT EXPERIENCE
START WITH YOUR CURRENT EMPLOYMENT OR LAST JOB HELD. INCLUDE MILITARY SERVICE,
ASSIGNMENTS, AND VOLUNTEER ACTIVITIES. (YOU MAY EXCLUDE ORGANIZATION NAMES THAT INCLUDE
RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, DISABILITY, OR OTHER LEGALLY PROTECTED
STATUS). PLEASE LIST PAST TEN YEARS OF EMPLOYMENT. THIS SECTION IS TO BE COMPLETED IN DETAIL
TO INCLUDE CITY, STATE, ZIP CODE, PHONE NUMBERS, SUPERVISOR’S TITLE, ETC.
DO NOT WRITE REFER/SEE RESUME. COMPLETE ALL BLANKS IN FULL.
Name of Employer
Dates employed
(From/To)
Street Address
Apartment #
City, State, Zip Code
Supervisor’s Name
Supervisor’s Email
Supervisor’s Phone Number
Job Position You Held
Reason for Leaving
Describe Detailed Work Performed
Revised November 2019
Name of Employer
Dates employed
(From/To)
Street Address
Apartment #
City, State, Zip Code
Supervisor’s Name
Supervisor’s Phone Number
Job Position You Held
Reason for Leaving
Describe Detailed Work Performed
Supervisor's Email
Revised November 2019
Name of Employer
Dates employed
(From/To)
Street Address
Apartment #
City, State, Zip Code
Supervisor’s Name
Supervisor’s Email
Supervisor’s Phone Number
Job Position You Held
Reason for Leaving
Describe Detailed Work Performed
Revised November 2019
Name of Employer
Dates employed
(From/To)
Street Address
Apartment #
City, State, Zip Code
Supervisor’s Name
Supervisor’s Email
Supervisor’s Phone Number
Job Position You Held
Reason for Leaving
Describe Detailed Work Performed
IF YOU NEED ADDITIONAL PAGES FOR YOUR EMPLOYMENT, YOU CAN
MAKE COPIES OF THIS PAGE.
NOTE: IF YOU ARE MAILING IN YOUR EMPLOYMENT APPLICATION,
PLEASE PRINT ALL PAGES SINGLE ON A SINGLE PAGE.
Revised November 2019
EDUCATIONAL HISTORY
Schools
Attended
Name of School / City, State
Diploma/Degree Achieved/Subject
High School
College
University
Other
Describe specialized training, apprenticeship, skills or extra-curricular activities that would be beneficial to the
position for which you are applying. (You may exclude organization names which include race, color, religion,
gender, national origin, disability or other legally protected classes).
\
REFERENCES
PLEASE LIST NAMES OF THREE (3) PROFESSIONAL REFERENCES ONE MUST BE A SUPERVISOR. (PLEASE ASTERISK * THE
SUPERVISOR):
YEARS
NAME TEL. NO. OCCUPATION KNOWN EMAIL
*________________________________ _________________ _____________________________ ___________ ____________________
________________________________ _________________ _____________________________ ___________ ____________________
________________________________ _________________ _____________________________ ___________ ____________________
MAY WE CONTACT YOUR CURRENT SUPERVISOR? YES NO
If you responded no, please provide an alternative supervisorial professional reference:
NAME TEL. NO. OCCUPATION KNOWN EMAIL
*________________________________ _________________ _____________________________ ___________ ____________________
Revised November 2019
CITY OF GROTON AGREEMENT AND RELEASE
TO ALL APPLICANTS: PLEASE READ THIS SECTION CAREFULLY AND SIGNIFY YOUR UNDERSTANDING BY
SIGNING YOUR NAME IN THE SPACE INDICATED BELOW:
I certify that all of the statements made by me on this application for employment are true, correct, and complete to the best of my
knowledge. I understand that any falsification or material omission of fact on this application shall lead to refusal of employment or
dismissal from employment.
I authorize the City of Groton to check the references provided, and further authorize the investigation of all matters contained in this
application to verify its accuracy. I understand that all employment appointments are probationary, during which time I must
demonstrate my fitness for continued employment.
I understand that, as part of the application procedure for employment at the City of Groton, I will be required to submit to a urinalysis
test to detect the existence of drugs and other intoxicants. The test will be administered as required by State or Federal Law. I further
understand that, if the test is positive, I will be given a copy of the results, if requested.
I understand that as part of the application process, the City of Groton conducts thorough background checks (which may include a
check of my criminal history) and credit checks done on prospective employees. I agree, if contacted with respect to such background
check, that I will fully cooperate and provide any information requested.
The applicant is not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been
erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a. The applicant is not required to disclose the
existence of criminal records that are subject to erasure pursuant to Connecticut General Statutes sections 46b-146, 54-76o and 54-142a
which are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication
as a youthful offender, a criminal charge that has been dismissed or nullified, a criminal charge for which the person has been found
not guilty or a conviction for which the person received an absolute pardon, and the applicant is not required to disclose the existence
of criminal records that have been erased pursuant to Connecticut General Statutes, Sections 46b-146, 54-76o or 54-142a since the
applicant shall be deemed to have never been arrested within the meaning of the General Statutes with respect to these proceedings so
erased and may so swear under oath.
As a condition of employment I understand that information relative to the status of any driver’s duties, particularly insurability of a
driver by the City of Groton, is a vital job function.
As a condition of my employment, I hereby authorize my employer and its insurance agent to ask for and receive information relative
to the status of my motor vehicle operator’s license and motor vehicle history in every State in which I have held a motor vehicle
operator’s license.
This authorization is valid from the date of my signature below throughout the term of my employment in which driving a City of
Groton motor vehicle is an essential job function.
I understand that if at any time (now or in the future) the City of Groton cannot insure me due to my motor vehicle operator history my
employment will be terminated.
AUTHORIZATION AND RELEASE
I hereby authorize all previous employers and references to release to the City of Groton, any and all employment and personnel
information requested, including, but not limited to my personnel file(s). I hereby also specifically release and hold harmless the City
of Groton, or any former employer and its employees and/or agents from any and all claims or liability as a result of releasing such
information.
__________________________________________ __________________________________
APPLICANT’S SIGNATURE DATE
(This employment application must be signed in ink or by electronic signature)
CLEAR
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Revised November 2019
V O L U N T A R Y S E L F I D E N T I F I C A T I O N A P P L I C A N T D A T A F O R M
I N S T R U C T I O N S
P L E A S E R E A D A L L I N S T R U C T I O N S C A R E F U L L Y B E F O R E C O M P L E T I N G T H I S F O R M
Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual,
or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of
such individual’s race, ethnicity, color, religion, sex, national origin, pregnancy, or gender identity.
This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which
require the employer to invite employees to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary
and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may
only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which
require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes.
If you choose not to self-identify your race/ethnicity at this time, the federal government requires this employer to determine this
information by visual survey and/or other available information.
For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven
categories identified below. The definitions for each category have been established by the federal government. If you choose to
voluntarily self-identify, you may mark only one of the boxes presented below.
INVITATION TO SELF-IDENTIFY
PLEASE ANSER THE FOLLOWING QUESTION
DATE: POSITION APPLIED FOR:
REFERRAL SOURCE:
Advertisement Friend Relative Walk-in Employment Agency Other
If other please specify referral source: ______________________
GENDER: Male Female Other
VETERAN STATUS: Veteran: Branch of service ____________ and years: ____________
Active Reserves
Not Applicable
What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify.
Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture
or origin, regardless of race.
White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American: a person having origins in any of the black racial groups of Africa.
Asian: 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.
Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment.
Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity categories.
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Application For Employment Revised 11 25 19

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Completed 18 July 2020

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