Fill - Free fillable Ellsworth Job App Employment Application PDF form

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City of Ellsworth

1 City Hall Plaza

Ellsworth, ME 04605

Phone (207) 667-2563 ♦ Fax (207) 667-4908 ♦ www.ellsworthmaine.gov

Employment Application

We are an equal opportunity Employer

Date

Job Title/Position Opening you are applying for:

Last Name First Name

Address Phone

Address Email

All applicants who are offered employment must provide documentation to establish their identity and employment

eligibility for authorization to work in the U.S and must undergo a thorough background check.

Do you have the legal right to work in the U.S?

Date of Birth (if less than 18 years old):

Driver’s License No. & State: Class: Expiration Date:

Have you ever been employed by or done any volunteer work for the City of Ellsworth?

Do you have any relatives employed with the City of Ellsworth?

(If yes, please list name(s):

Please list all traffic convictions or accidents in the past 3 years:

Please list other names you have used in the past:

Have you ever been convicted of a crime? If yes, please give explanation.

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Education

Did you receive a High School Diploma or GED equivalent?

Name of High School and location:

Name of School, College,

Or University

Major

Credit Hours

Degree*

*Proof of degrees from College/University will be required.

Name of Trade, Technical, Business,

Other School

Course of Study

Diploma

List other licenses held, date & license number; professional registrations & dates; certificates & professional

memberships:

List Honors, Awards, Fellowships:

Skills Overview

List computer software with which you are familiar:

List languages, other than English, that you speak fluently, read and/or write:

Summarize relevant skills & experience that exemplify your qualifications for the above position:

List tools & equipment you can operate:

Summarize Volunteer Services work you have done, including dates:

Summarize Leadership Roles you have experienced:

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Employment History

Current or most recent employer:

Address: Phone:

Your Title: Dates of Employment – From: To:

Supervisor’s Name/Title:

Salary – Starting: Ending: Hrs. per Week:

Work/Tasks Performed:

Reason for Leaving:

Next most recent employer:

Address: Phone:

Your Title: Dates of Employment – From: To:

Supervisor’s Name/Title:

Salary – Starting: Ending: Hrs. per Week:

Work/Tasks Performed:

Reason for Leaving:

Next most recent employer:

Address: Phone:

Your Title: Dates of Employment – From: To:

Supervisor’s Name/Title:

Salary – Starting: Ending: Hrs. per Week:

Work/Tasks Performed:

Reason for Leaving:

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City of Ellsworth

AUTHORIZATION FOR RELEASE OF INFORMATION

I, (print name) hereby authorize an employee of the City of

Ellsworth or other authorized representative bearing this release (or facsimile or copy) to, within one year of its

date, obtain information from past and/or current employers listed on the Employment Application as submitted

by me on (date) .

Employer’s Name:

Contact Person:

Employer’s Address:

I have filed an application for employment with the City of Ellsworth, Maine. Information regarding my

employment with your organization is as follows:

Dates of employment: From To

Position:

I hereby empower an employee of the City of Ellsworth or other authorized representatives bearing this release

(or facsimile or copy) to, within one year of its date, obtain information and records pertaining to me from any

or all of the following sources:

1. Municipal, State or Federal law enforcement agencies.

2. Selective Service System.

3. Any banking institution.

4. Any place of business (for purposes of obtaining credit or employment data).

5. Credit rating bureaus or institutions maintaining individual credit rating files.

6. Any previous employer.

7. Present employer.

8. Any school, college, university or other educational institution.

9. Other:

I hereby release any Municipal, State, or Federal law enforcement agency, individual or institution, including its

officers, employees, or related personnel, both individually and collectively, from any and all liability for

damages of whatever kind, which may at any time result to me, my heirs, family or associates because of

compliance with this authorization and request to release information or any attempt to comply with it.

Exceptions to this blanket authorization are:

NAME Address

SIGNATURE Date

Witness: Title:

Any information furnished relative to the application of the above individual will be treated with strictest confidence. An

applicant typically will not be eliminated or selected on the basis of a single reference. Please complete the employment

reference section attached.

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City of Ellsworth, 1 City Hall Plaza, Ellsworth, ME 04605

BACKGROUND CHECK AUTHORIZATION

I, (print name) have filed an application for employment with the City of

Ellsworth, Maine for the position of ______________________________________ and understand that in

order to assess my qualifications a full background investigation is necessary. Certain positions may also be

conditioned on the successful completion of agility tests, skill evaluations, additional investigations and/or the

ability to be bonded. I therefore authorize the City of Ellsworth to conduct an investigation which may include

but not be limited to:

• Verification of all information provided by me to the City during the application process.

• Contacting employers (past and present), clients, business associates, professional organizations, or

other institutions, regarding work performance and character.

• Verification of licensure and/or educational attainment.

• Military Service Records.

• Complete Criminal Background Check. (Including State & Federal Law Enforcement Agencies)

• Credit check.

• Driver’s license check.

• Other:

I certify that all the information and materials I have provided to the City of Ellsworth as part of the

employment process are accurate and truthful. I realize that providing the City with false information or

intentionally withholding relevant information regarding my application may be grounds for rejection or

dismissal. If employed, I agree to provide proof of identity, relevant licensure or credentials, and authorization

for employment in the United States. Upon employment, I agree to abide by all municipal policies, regulations,

ordinances and established work safety practices.

I hereby agree to hold harmless and to release the City of Ellsworth, including its officers and employees or

related personnel, both individually and collectively, from any and all liability for damages of whatever kind,

which may at any time result to me, my heirs, family or associates because of compliance with this

authorization to conduct a thorough background investigation.

PRINT NAME Current Address

Email Contact Information:

Telephone Contact Information:

Home Cell

Previous Addresses or Cities lived in within past 10 years

Social Security # Date of Birth Drivers License #

SIGNATURE Date

Fill Online, Printable, Fillable, Blank Ellsworth Job App Employment Application Form

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Fillable Ellsworth Job App Employment Application

Fill Online, Printable, Fillable, Blank Ellsworth Job App Employment Application Form

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