CITY OF GROTON APPLICATION FOR SEASONAL EMPLOYMENT
PLEASE NOTE: Applications for employment must be completed in full with an original signature by the
applicant for consideration in the hiring process. Attaching a resume does not relieve the applicant of this
requirement.
DO NOT USE ANY PREVIOUS APPLICATIONS AS THEY ARE OBSOLETE.
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
LAST NAME _______________________________ FIRST NAME _____________________ MIDDLE NAME __________________
PRESENT ADDRESS _________________________________________________________________________________________________
HOME PHONE # ___________________________________ CELL PHONE # ___________________________________
EMAIL ADDRESS _____________________________________________________________________________
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE USA? YES NO
IF YES, VERIFICATION WILL BE REQUIRED.
ARE YOU UNDER THE AGE OF 18? YES NO
IF YOU ARE UNDER 18 YEARS OF AGE, PLEASE PROVIDE YOUR DATE OF BIRTH ____________________
EMPLOYMENT DESIRED
POSITION(S) APPLIED FOR (USED SPECIFIC POSITION ON WEBSITE) ___________________________________________________
_______________________________________________________________________________________________________________________
DATE AVAILABLE TO START WORK: ____________________________ HOURLY RATE ____________________________
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE
SHEET OF PAPER. DO NOT DOUBLE SIDE.
12/17
Revised 1/30/19
ARE YOU CURRENTLY EMPLOYED? YES NO
HAVE YOU EVER APPLIED TO WORK FOR THE CITY OF GROTON BEFORE? YES NO
YEAR APPLIED _______________________________ WHAT DEPARTMENT? __________________________
EMPLOYMENT INFORMATION
ARE YOU PHYSI
CALLY AND MENTALLY ABLE TO PERFORM THE JOB APPLIED FOR? YES NO
(If NO, is t
here any accommodation that would allow you to perform this job?) YES NO
DO YOU HAVE ANY OB
JECTION TO WORKING OVERTIME WITHOUT PRIOR NOTICE? YES NO
CAN YOU TRAVEL O
UT OF STATE IF REQUIRED BY THIS POSITION? YES NO
LICENSE INFORMATION
IF YOU ARE APPLYING FOR A SEASONAL LABORER POSITION PLEASE PROVIDE THE FOLLOWING
INFORMATION:
LICENSE #_
__________________________ STATE ISSUED _______________ EXPIRATION DATE_____________
PLEASE ATTACH A COPY OF YOUR LICENSE WITH THE APPLICATION.
___________________
______________ ______________________ _______________________
PRINT NAME SIGNATURE DATE
(THIS S
TATEMENT MUST BE SIGNED WHETHER YOU ANSWERED YES OR NO ABOVE)
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A
SEPARATE SHEET OF PAPER. DO NOT DOUBLE SIDE
12/17
Revised 1/30/19
Rev. 1/17
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 FIVE YEARS OF EMPLOYMENT. THIS SECTION IS TO BE
COMPLETED IN DETAIL TO INCLUDE CITY, STATE, ZIP CODE, PHONE NUMBERS, SUPERVISOR’S TITLE, ETC. PLEASE DO NOT WRITE
REFER/SEE RÉSUMÉ.
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street Address
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE
SHEET OF PAPER. DO NOT DOUBLE SIDE.
Revised 1/30/19
Rev. 1/17
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street Address
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE
SHEET OF PAPER. DO NOT DOUBLE SIDE.
Revised 1/30/19
Rev. 1/17
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street Address
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
Employers Name
Dates Employed
Describe Detailed Work Performed
From
Month/year
Street
City/State/Zip Code
Your Job Title
Supervisor’s Name
Supervisor’s Phone Number
Your reason for leaving
IF YOU NEED ADDITIONAL PAGES FOR YOUR EMPLOYMENT, YOU CAN
MAKE COPIES OF THIS PAGE.
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE
SHEET OF PAPER. DO NOT DOUBLE SIDE.
Revised 1/30/19
Revised October 2018
EDUCATIONAL HISTORY
Schools
Attended
Name of School
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
*________________________________ _________________ _____________________________ ___________ ____________________
________________________________ _________________ _____________________________ ___________ ____________________
________________________________ _________________ _____________________________ ___________ ____________________
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE SHEET OF
PAPER. DO NOT DOUBLE SIDE.
Revised 1/30/19
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 certif
y 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 unde
rstand 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 unde
rstand that as part of the application process, the City of Groton conducts thorough background checks (which may include a
check of my criminal history) 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 c
ondition 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 con
dition 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 a
uthorization 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 unders
tand 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.
_________
___________________________ _______________________
APP
LICANT’S SIGNATURE DATE
NOTE: PLEASE PRINT EACH PAGE OF THE APPLICATION ON A SEPARATE
SHEET OF PAPER. DO NOT DOUBLE SIDE.
12/17
Revised 1/30/19
CLEAR
PRINT
Revised October 2018
VOLUNTARYSELFIDENTIFICATIONAPPLICANTDATAFORM
INSTRUCTIONS
PLEASEREADALLINSTRUCTIONSCAREFULLYBEFORECOMPLETINGTHISFORM
Anti‐DiscriminationNotice.Itisanunlawfulemploymentpracticeforanemployertofailor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
CHECKONEOFTHEFOLLOWING:MaleFemaleOther
Whatisyourrace/ethnicity?Pleasemarktheoneboxthat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anyoftheoriginal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.
Revised 1/30/19
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