The City of Douglas does not discriminate on the basis of Race, Color, National Origin, Sex, Religion, Age, Veteran Status, Genetics or Disability or any other
legally protected status in employment or the provision of services.
Your signed application can only be accepted in hard copy form. Please submit your completed application to:
City of Douglas HR Department
Fax: (520) 417-7155
425 10
th
Street, Douglas, AZ 85607
Tel: (520) 417-7326
Position Desired
Position Title:
Job Announcement Number:
Type of Position you are interested in: Full Time Part Time Temporary
Seasonal Weekends Shifts
When would you be available to start work?
Personal Data
Name:
Address:
City: State: Zip:
Mailing Address (If different from above)
Home Phone:
Office Phone:
Message Phone:
Cell Phone:
Email Address:
Driver’s License/CDL No. & State: Class:
If CDL, list all endorsements
Endorsements:
Are you legally authorized to work in the United States? Yes No
Have you ever worked or volunteered for the City of Douglas? Yes No
If yes, please give dates:
If you answered yes to the above question, and you were employed under a different name, please list the name
used:
Are any of your relatives employed by the City of Douglas? Yes No
Explain:
Rev. 12/28/2018
CITY OF DOUGLAS
Employment Application
An affirmative action and equal opportunity employer.
CITY OF DOUGLAS
Employment Application
Education
Do you have a High School Diploma accredited in the U.S.? ______Yes ______ No
If yes, give
name and place of school of graduation:
Do you have a G.E.D. certificate? Yes No
College(s) or University
Name and Location
Major
Degree
Date
Business/Vocational/Technical Schools
Name and Location
Course of Study
Diploma & Date
List License (date & #), professional registrations (date), certificates and professional memberships:
List Honors, Awards, Fellowships:
Skills Overview
Approximate Typing Speed in words per minute:
List computer software with which you are familiar:
List all languages you can speak, read,
write and understand to include English.
Language(s):
Speak:%
Read:%
Write: %
Please summarize relevant skills and experience that exemplify your qualifications for the above position:
References:
Give name, address and telephone number of three references who are not related to you.
CITY OF DOUGLAS
Employment Application
Employment History
Current or most recent employer: Phone:
Address:
Your Title: Number of workers you directly supervised:
Employment Dates From: To:
Supervisor’s name/title:
Starting Salary: Present/Ending: Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
Employer:
Phone:
Address:
Your Title: Number of workers you directly supervised:
Employment Dates From: To:
Supervisor’s name/title:
Starting Salary: Ending: Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
Employer:
Phone:
Address:
Your Title: Number of workers you directly supervised:
Employment Dates From: To:
Supervisor’s name/title:
Starting Salary: Ending: Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
CITY OF DOUGLAS
Employment Application
Employment History
Employer: Phone:
Address:
Your Title: Number of workers you directly supervised:
Employment Dates From: To:
Supervisor’s name/title:
Starting Salary: Ending: Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
Employer:
Phone:
Address:
Your Title:
Number of workers y
ou directly supervised:
Employment Dates From:
To:
Supervisor’s name/title:
Starting Salary:
Ending:
Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
Employer:
Phone:
Address:
Your Title:
Number of workers you
directly supervised:
Employment Dates From:
To:
Supervisor’s name/title:
Starting Salary:
Ending:
Hours per week:
Description of Duties:
Reason for leaving or wanting to change:
CITY OF DOUGLAS
Employment Application
Affirmation Statement/Signature
The above information is true and complete. I understand that false statements on this application or any verbal or written
misleading or false representation made in the course of the selection process may be deemed sufficient cause for
dismissal.
In compliance with the Immigration Reform & Control Act of 1986, I will submit proof of work eligibility if hired by the City of
Douglas.
Signature: ______________________________________________________________ Date: ______________________
For Human Resource Department Use Only
MQs
Yes No
T&E Score
Code
Temporary/Limited/Seasonal
Placed on hiring list
Yes No
Notified of Status
Yes No
Notes:
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________________________________________________________________________________
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__________
_________________________________________________________________________
click to sign
signature
click to edit
CITY OF DOUGLAS
Employment Application
APPLICANT INFORMATION SURVEY
Instructions: The City of Douglas is an Equal Opportunity Employer. The information solicited on this page is being
compiled by the City of Douglas HR Department to comply with Federal EEO/Affirmative Action record keeping regulations
and to enable related statistical research. You are not required to furnish this information, but your cooperation is
encouraged. The information provided on this form is CONFIDENTIAL. This survey will be removed from your application
prior to the review process.
Date:
Position Title:
Job Announcement Number:
Indicate your choice of responses for items A - F by placing an X in the appropriate box.
A. Ethnic Category:
Check only one (definition of categories are below.)
White (WH) African American (BL)
Hispanic (HI) Asian (AS)
Native American (AI)
B. Sex
Male (M) Female (F)
C. Age Group
Under 20 (19) 20-29 (20)
30-39 (30) 40-49 (40)
50-59 (50) 60+ (60)
D. Veteran Status
I am a veteran of the United I am not a veteran. (2)
States Armed Forces, honorably separated
following more than 180 days of active duty.
Excluding training and reserve duty. (1)
I am a spouse of a I am the spouse of an Active
permanently disabled veteran. (3) duty Armed Forces member who is missing in action.(4)
E. Are you disabled? (For definition of “disabled” see below.)
Yes (1) No (2)
CITY OF DOUGLAS
Employment Application
EQUAL EMPLOYMENT OPPORTUNITY SURVEY DEFINITIONS
1. White: Includes persons having origins in any of the original peoples of Europe, North Africa, the Middle East, or the
East Indian Subcontinents.
2. Black: Includes persons having origins in any of the Black racial groups.
3. Hispanic: Includes persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture
or origin, regardless of race.
4. American Indian or Alaskan Native: Includes persons having origin in any of the original peoples of North
America.
5. Asian or Pacific Islander: Includes persons having origins in any of the original peoples of the Far East,
Southeast Asia or the Pacific Islands (China, Japan, Korea, Samoa, etc.)
6. Disabled: Anyone who has a physical or mental impairment which substantially limits one or more major life
activities or has a record of such impairment or is regarded as having such an impairment.
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