CITY OF BERLIN
APPLICATION FOR EMPLOYMENT
The City of Berlin is an equal opportunity employer. Discrimination on the basis of age, sex, race,
color, marital status, physical or mental disability, religious creed, national origin, sexual orientation
or any other non-merit factor is strictly prohibited.
APPLICANT INFORMATION
Name:
_________________________________________________________
(LAST) (FIRST) (MIDDLE)
Mailing
Address:______________________________________________________________________________
(STREET, P.O. BOX)
_______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
_______________________________________ _____________________________________
HOME PHONE /CELL WORK PHONE/EXT
FOR OFFICIAL USE ONLY
Received by: ________________
Department: ________________
Be sure to fill in the "Applicant Information" section at the top of this application. You are encouraged to provide a copy
of your current resume.
Position for which you are applying:
Pay Desired: Date you can start:
Will you accept part time employment: Yes
No
How many hours per week do you currently work?
Do you have the legal right to accept employment in the United States? Yes
No
Have you ever been employed by the City of Berlin? Yes
No
If yes, when?
(MM/DD/YYYY)
Have you ever been convicted of or pleaded no contest to a crime which was not annulled by a court? Yes
No
If Yes, explain; this does not automatically exclude you from consideration.
EDUCATION
Please select the highest school grade completed:
8
9
10
11
12 or GED
13
14
15
16
17
18
Are there any specialized courses you have taken that you want considered in reviewing this application? Please explain below:
If the position for which you are applying requires post secondary education credits, YOU MUST SUBMIT COPIES OF
COLLEGE, BUSINESS, TRADE SCHOOL, AND/OR OTHER EDUCATION TRANSCRIPTS.
Name of School Major Degree or Certificate Earned
INFORMATION TECHNOLOGY TRAINING/EXPERIENCE
Please list below your training/experience in information technology (i.e., data processing, word processing, spreadsheet design,
or development, database development or management). Note any specific software applications or programming languages in
which you are proficient:
LICENSES AND CERTIFICATION
Please list any license or special certification that you hold, specifying license/certificate number and date of expiration:
CDL # _____________________________ Class __________________________ Expires _____/_____/_____
PE/EIT # ___________________________________________________________ Expires _____/_____/_____
LPN # _____________________________________________________________ Expires _____/_____/_____
RN # _____________________________________________________________ Expires _____/_____/_____
Other: _____________________________________________________________ Expires _____/_____/_____
EXPERIENCE - WORK HISTORY
In the section below, please describe your experience/work history (including pertinent volunteer experience), beginning with
your current or most recent position. Attach additional sheets if necessary.
Employer: _______________________________________ Address: _____________________________ Phone: __________
Your Job Title: ___________________________________ Supervisor's Name/Title: __________________________________
Dates of Employment: From: Mo. ___ Yr. ___ to Mo. ___ Yr. ___ May we contact? Yes
No
Please describe the duties you performed in your position:
Reason you left the position:
_____________________________________________________________________________________________________
Employer: _______________________________________ Address: _____________________________ Phone: __________
Your Job Title: ___________________________________ Supervisor's Name/Title: __________________________________
Dates of Employment: From: Mo. ___ Yr. ___ to Mo. ___ Yr. ___ May we contact? Yes
No
Please describe the duties you performed in your position:
Reason you left the position:
_____________________________________________________________________________________________________
Employer: _______________________________________ Address: _____________________________ Phone: __________
Your Job Title: ___________________________________ Supervisor's Name/Title: __________________________________
Dates of Employment: From: Mo. ___ Yr. ___ to Mo. ___ Yr. ___ May we contact? Yes
No
Please describe the duties you performed in your position:
Reason you left the position:
_____________________________________________________________________________________________________
Employer: _______________________________________ Address: _____________________________ Phone: __________
Your Job Title: ___________________________________ Supervisor's Name/Title: __________________________________
Dates of Employment: From: Mo. ___ Yr. ___ to Mo. ___ Yr. ___ May we contact? Yes
No
Please describe the duties you performed in your position:
Reason you left the position:
_____________________________________________________________________________________________________
REFERENCES
Names of three persons not related to you whom you have known at least one year.
Name Address Telephone Business
Name Address Telephone Business
Name Address Telephone Business
I certify that the information provided in or attached to this application is complete, accurate and up-to-date on the date specified
below. I certify that I have the legal right to accept employment in this State, and that I will produce, at or before the date of hire,
proof of that right to accept employment. I further certify that there are no willful misrepresentations of the above statements and
answers to questions herein, and that I have made no omissions of material fact with respect to any of my answers to the questions
presented. I understand that if an investigation should disclose such misrepresentations or omissions, my application may be
rejected. Finally, I understand that if I should be employed at the time of such investigations and disclosure, my services may be
immediately terminated.
By checking this box, you are certifying that you have read and agree to the above statement.
SIGNATURE OF APPLICANT: DATE:
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