Employment Application
Date:
Name:
Address:
State/Province:
Zip/Postal Code:
SS Number:
Home Phone:
Cell Phone:
Positions Applied for:
Salary Desired:
Hours Available to Work:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Full-Time part-time Full or part-time
When available to begin work?
City of Galva
311 N.W. 4th Avenue
Galva, IL 61434
Phone: (309) 932-2555
Fax: (309) 932-3306
www.galvail.gov
Education
Type of School Name of School and Complete Mailing Address No. Years Completed Major or Degree
High School
College Bus. or
Trade School
Professional School
Other
Have you ever been convicted of a crime: yes no
If yes, please explain
Do you have a drivers license?
yes no
State of issue:
Have you had any accidents in the past 3 years?
yes no
How many?
Do you had any moving violations in the past 3 years?
yes no
How many?
Continue on the next page
Previous Employment (list up to 3)
1.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
2.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
Continue on the next page
3.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
Skills:
Typing:
Computer:
PC Mac Both
Applications (list all that apply):
Other Skills:
Please list 2 references other than relatives and previous employers
Name
Position
Company
Telephone
Use this space to add any additional information necessary to describe your full qualifications for the position which you are applying:
Continue on the next page
AUTHORIZATION
I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the
best of my knowledge. I understand that any false statement, omission, or representation on this application is
sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the City of
Galva.
I understand that any employment is conditioned on a background check. I authorize the City of Galva to
thoroughly investigate all statements contained in my application or resume, and I authorize my former employers
and references to disclose information regarding my former employment, character and general reputation to the
City of Galva, without giving me prior notice of such disclosure. In addition, I release the City of Galva, any former
employers and all references listed above from any and all claims, demands or liabilities arising out of or related to
such investigation or disclosure.
I understand and agree that nothing contained in this application, or conveyed during my interview, is
intended to create an employment contract. I further understand and agree that if I am hired, my
employment will be "at will" and without fixed term, and may be terminated at any time, with or without
cause and without prior notice, at the option of either myself or the City of Galva. No promises regarding
employment have been made to me, and I understand that no such promise or guarantee is binding upon
the City of Galva unless made in writing.
If I am offered employment, I agree to submit to a medical examination and drug test before starting work. If
employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the City
of Galva and as permitted by law. I consent to such examinations and tests, and I request that the examining
doctor disclose to the City of Galva the results of the examination, which results shall remain confidential and
segregated from my personnel file. I understand that my employment or continued employment, to the extent
permitted by law, is contingent upon satisfactory medical examinations and drug tests, and if I am hired a
condition of my employment will be that I abide by the City of Galva's Drug and Alcohol Policy.
I understand that filling out this form does not indicate there is a position open and does not obligate the City of
Galva to hire. If hired, I agree to abide by all City of Galva work rules, policies and procedures. The City of Galva
retains the right to revise its policies or procedures, in whole or in part, at any time.
Date: Signature:
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