CITY OF BEREA
EMPLOYMENT APPLICATION
RETURN APPLICATIONS TO: HUMAN RESOURCES, 212 CHESTNUT STREET, BEREA, KY 40403
Complete Online, Print, Sign, Return to Above Address
Position Applied for:
Date of application:
Last Name: First Name:
MI:
Number/Street
ADDRESS:
City: State: Zip Code:
Telephone No: Cell No:
Social Security Number:
If you are under 18 years of age, can you provide required proof of your
eligibility to work?
Yes No
Have you ever been employed with the City of Berea before?
Yes No
If yes, please give date and department:
Date:
Department:
Are you currently employed?
Yes No
May we contact your present employer? Yes No
Are you prevented from lawfully becoming employed in this country
because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment)
Yes No
On what date would you be available for work?
Date:
N/A
Driver's License # State of Issue
E-Mail Address:
Have you been convicted of a felony within the last 7 years? Yes No
Conviction will not necessarily disqualify an applicant from employment.
If yes, please explain:
EDUCATION: Please list your highest level of education.
Undergraduate
College or
University
Graduate School or
Professional
School Name &
location
High School
Years Completed:
Date graduated:
Diploma/Degree:
Describe honors
received:
Additional
information
(Include your
course
of study)
Can you travel if a job requires it?
Yes No
Are you currently on “lay-off” status and subject to recall?
Yes No
Are you available to work?
Full-Time Part-Time
Seasonal
REFERENCES:
Give name, address and telephone number of three (3) references who are not related to you and
are not previous employers:
1.
2.
3.
Have you ever had any job-related training in the United States military? Yes No
If yes, please describe:
Are you capable of performing in a reasonable manner, with or without a
reasonable accommodation, the activities involved in the job for which you
have applied? A description of the activities involved in this job is available
upon request.
Yes No
Describe any specialized training, apprenticeship, skills or extra-curricular activities you have
completed that would aid in your ability to perform the position applied for:
EMPLOYMENT EXPERIENCE
Start with your present or last job. Include any job-related military service assignments and
volunteer activities. You may exclude organizations which indicate race, color, religion, gender,
national origin, handicap or other protected status. If you need additional space, please continue on
a separate sheet of paper.
1. Employer Address:
City: State: Zip Code:
Telephone no: Title: Supervisor:
Dates employed: From: To:
Reason for leaving:
Starting hourly rate: Ending hourly rate:
Ending hourly rate:Starting hourly rate:
Reason for leaving:
To:Dates employed: From:
Supervisor:Title:Telephone no:
Zip Code:State:City:
Address:2. Employer
Ending hourly rate:Starting hourly rate:
Reason for leaving:
To:Dates employed: From:
Supervisor:Title:Telephone no:
Zip Code:State:City:
Address:3. Employer
Ending hourly rate:Starting hourly rate:
Reason for leaving:
To:Dates employed: From:
Supervisor:Title:Telephone no:
Zip Code:State:City:
Address:4. Employer
Special Skills and Qualifications: Please summarize special job-related skills and qualifications
acquired from employment or other experience. You may exclude organizations which indicate race,
color, religion, gender, national origin, handicap or other protected status.
APPLICANT'S STATEMENT: I certify that answers given herein are true and complete to the best of
my knowledge. I authorize investigation of all statements contained in this application for
employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 60 days
Any applicant wishing to be considered for employment beyond this time period should inquire as to
whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any
employment relationship with this organization is of an “at will” nature, which means that the
Employee may resign at any time and the Employer may discharge the Employee at any time with or
without cause. It is further understood that this “at will” employment relationship may not be
changed by any written document or by conduct unless such change is specifically acknowledged in
writing by an authorized executive of this organization.
In the event of employment, I understand that false or misleading information given in my application
or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and
regulations of the employer, including submitting to a pre-employment drug screen.
Date:
_____________________________________________________________________
Signature of applicant
Employees are treated during employment without regard to race, color, religion, sex, national origin,
age, marital or veteran status, medical condition or handicap, or any other legally protected status. As
an employer with an Affirmative Action Program, we comply with government regulations, including
Affirmative Action responsibilities where they apply.
APPLICATION PROCESS: To receive consideration, applicants must complete this application in full. If
a resume is submitted for part of the information requested on this application, applicants must be
certain that the resume contain all of the information on this application.
Complete Online, Print, Sign, Return to Above Address
How did you hear about this job: __ City Website __ Facebook __ Newspaper __ Other: _______________
RETURN APPLICATIONS TO: HUMAN RESOURCES, 212 CHESTNUT STREET, BEREA, KY 40403
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