CITY OF COLUMBIANA
APPLICATION FOR EMPLOYMENT
Applicants may request reasonable accommodation in the application/interview process.
PLEASE PRINT
Name:
LAST FIRST MIDDLE
Address:
STREET CITY STATE ZIP CODE
Telephone: Social Security Number:
Application Date: Veteran: !Yes ! No Branch of Service
Are you legally permitted to work in the United States? ! Yes ! No
PERSONAL DATA
Position(s) desired: Full-Time ! Part-Time !
Date available to start?
Have you previously applied for a job with the City? Yes ! No ! When:
Have you ever been employed by the City? Yes ! No ! When:
Reason for leaving?
Are you related to anyone employed by the City? Yes ! No !
State name and relationship:
Do you have any time commitments that might interfere with your employment? Yes ! No !
If yes, please explain
Have you ever been employed by another public employer in Ohio? Yes ! No !
If yes, provide place and dates of service
Have you ever been dismissed from or asked to resign from any employment position? Yes ! No !
If yes, please explain:
Have you ever been convicted of a crime (felony or misdemeanor) other than a minor traffic violation? Yes ! No !
If yes, please explain:
If the job posting listed a driver's license or commercial driver's license as required for the job, please answer the following:
Do you have a valid Ohio driver's license? Yes ! No !
Do you presently have a valid Ohio commercial driver's license? Yes ! No !
If not, are you able to obtain an Ohio commercial driver’s license? Yes ! No !
Has your driver's license been suspended or revoked within the last three (3) years? Yes ! No !
Have you had any traffic violations in the past three (3) years? Yes ! No !
If yes, please list:
OFFENSE APPROXIMATE DATE/YEAR
If employed, why do you wish to leave your present employer?
May we contact your present employer for a reference? Yes ! No !
Describe briefly the type of work which you are best qualified to do by reason of background, education, previous employment or training, and
tell why you feel qualified for the position(s) for which you are applying:
List professional organization memberships and offices held, excluding those which would indicate race, color, religion, sex, age, national
origin, political affiliation, disability and/or ancestry:
EDUCATIONAL DATA
NAME OF SCHOOL OR COLLEGE
LOCATION
CITY, STATE, ZIP
MAJOR
SUBJECT/DEGREE
SCHOLASTIC
AVERAGE
DID YOU
GRADUATE?
HIGH SCHOOL
COLLEGE OR UNIVERSITY
OTHER SCHOOLS ATTENDED
OTHER (SPECIFY)
EMPLOYMENT DATA
List all previous employment for the last ten (10) years in chronological order - last position first - including U.S. Military. Attach additional
pages if needed or resume if desired.
EMPLOYER
ADDRESS
DATES EMPLOYED
POSITION(S) HELD
FROM TO
REASON FOR LEAVING
EMPLOYER
ADDRESS
DATES EMPLOYED
POSITION(S) HELD
FROM TO
REASON FOR LEAVING
EMPLOYER
ADDRESS
DATES EMPLOYED
POSITION(S) HELD
FROM TO
REASON FOR LEAVING
PERSONAL REFERENCES OTHER THAN FORMER EMPLOYERS AND RELATIVES
NAME
ADDRESS AND TELEPHONE
OCCUPATION
1.
2.
3.
Applicants for employment with the City of Columbiana are evaluated and selected on the basis of individual merit and ability with respect to
the position being filled. Applicants are selected and hired without consideration of race, color, religion, sex, age, national origin, political
affiliation, disability or ancestry.
CERTIFICATION
I certify that all information contained in this application is true, complete and correct to the best of my knowledge. I understand
that any material omission, misrepresentation or falsification of this information is grounds for dismissal from or refusal of
employment. I hereby authorize the investigation of all statements contained in this application and give permission to contact all
or any of my previous employers, references and/or schools for information unless otherwise noted in this document. I also give
my consent to contact the Bureau of Motor Vehicles for a Moving Vehicle Violation Report if such information is required to
perform the duties of the position. I indemnify and hold harmless all persons either providing or receiving information, verbal or
written, pursuant to this application.
APPLICANT'S SIGNATURE DATE
Applicants must submit a new application for consideration for a new position.
FOR INTERNAL USE ONLY
ARRANGE INTERVIEW: YES ? No ?
REMARKS:
INTERVIEWER'S SIGNATURE DATE
EMPLOYED: YES ! NO ! STARTING DATE: STARTING RATE:
JOB TITLE:
City of Columbiana 28 West Friend Street Columbiana, OH 44408
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