Fillable Employee Application Form 4 (Village of Brooklyn)

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Employee Application Form 4 (Village of Brooklyn)

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  • 36 check-boxes
  • 119 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Village of Brooklyn

BROWSE VILLAGE OF BROOKLYN (WI) FORMS

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210 Commercial Street • P.O. Box 189
Brooklyn, Wisconsin 53521-0189
Phone: (608) 455-4201 • Fax: (608) 455-1385
email: clerk@brooklynwi.gov
APPLICATION FOR EMPLOYMENT
(PLEASE TYPE OR PRINT CLEARLY)
Title of Position Applied For:
Name: Soc. Sec.# Phone
Address (Include Zip Code):
Have you ever been employed by the Village of Brooklyn? Yes ~ No ~
If yes, by whom, when, and in what position?
When will you be available for employment?
Do you currently hold a valid Wisconsin Driver’s License?
Yes No
DRIVER LICENSE NO.
Do you have transportation?
Yes ~ No ~
Check the highest grade or year completed in school
Name and Location of School
Graduated?
1 2 3 4 5 6 7 8 9 10 11 12
Yes ~ No ~
Training beyond high school, college or university, nursing, business college, or other schools you have attended. Under
credits earned, indicate number of hours, Q for Quarter hours and S for semester hours.
CHECK NUMBER OF YEARS IN COLLEGE OR UNIVERSITY
1 2 3 4 5 6 7 8
College, University, or School
Name and Location
Dates Attended
From To
Credits Earned
Major or Field Degree Conferred & Year
Describe any education or training you have had which is not covered above, such as vocational school, correspondence
courses, service schools, in-service training…give dates.
SPECIAL SKILLS & QUALIFICATIONS
Office Work:
Served formal apprenticeship? Yes ~ No ~
The following information must be provided if you are
applying for positions requiring typing or shorthand ability:
What trade?
How long?
Number of words per minute: Typing
When?
Shorthand
Where?
Experience with machine transcription? Yes No
Current license or registration as a member of some
trade or profession
List office machines other than typewriter which you can operate
skillfully:
List memberships in professional or technical associations:
The information obtained below will remain a part of the application only if the position applied for has particular security
requirements or if the employer feels there is a bona fide occupational qualification inherent in the position which requires
this information prior to hiring.
Have you ever been convicted of a crime other than a misdemeanor or summary offenses which have not been expunged
by a court? Yes ~ No ~ If yes, please explain: (Use additional sheet of paper if necessary.)
EQUAL OPPORTUNITY EMPLOYERS
Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age,
national origin or handicap.
Important: The information requested below is used to aid us in determining your qualifications for the position. It is
important that this data be as complete as possible in order that you receive maximum consideration. Please list present
and past full and part-time employment. Give special attention to experience relating to the job for which you are applying.
Be sure to give volunteer work and any related self-employment and military service. You need not go back beyond 10
years unless you feel prior experience is reasonably related to the position for which you are applying. Use additional
sheets if necessary. You may also attach a brief resume to further explain your qualifications.
From (Mo. & Yr.) Title of your PRESENT position Employer
’
s Name Phone
To (Mo. & Yr.)
Primary Duties
Address
Name & Title of Supervisor
How long employed?
Hours worked per week
Can we contact your present employer? Yes ~ No ~
Starting Salary Present Salary Reason for leaving or considering change
From (Mo. & Yr.) Title of position held Employer
’
s Name Phone
To (Mo. & Yr.) Primary Duties Address
Name & Title of Supervisor
How long employed?
Reason for leaving
Hours worked per week
Starting Salary
Last Salary
From (Mo. & Yr.) Title of position held Employer
’
s Name Phone
To (Mo. & Yr.)
Primary Duties Address
How long employed?
Name & Title of Supervisor
Hours worked per week
Reason for leaving
Starting Salary Last Salary
From (Mo. & Yr.) Title of position held Employer
’
s Name Phone
To (Mo. & Yr.)
Primary Duties
Address
Name & Title of Supervisor
How long employed?
Hours worked per week Reason for leaving
Starting Salary Last Salary
PERSONAL REFERENCES
Name & Occupation
Address
Phone
CERTIFICATION STATEMENT: (Read carefully before signing) All information provided by me is true and correct to the
best of my knowledge I understand that false statements, omissions or misrepresentations may be cause for rejection or, if
employed, may be cause for my immediate dismissal. By signing below, I also authorize the Village of Brooklyn and its assigns
("the Village") to perform a background check on all information provided by me on this application, including but not limited to
information relating to pending criminal charges, past criminal convictions, and education and employment history. I further
authorize any holder of information pertaining to the information supplied by me on this application to release such
information to the Village, which shall remain confidential pursuant to Wisconsin law. I understand and agree that the Village
shall not be held liable in any respect for any actions taken by the Village to check such information, nor shall the Village be
held liable in any respect if my employment is either denied or terminated as a result of any false statements, answers, or
omissions made by me on this application or on any other document submitted in connection with my application for
employment.
I understand this is a preliminary application and not a contract to employ me. If employed, I agree to comply with all rules of
the Village as a condition of continued employment.
Signature of Applicant Date
Authorization for Release of Information
(for official use only, not to be released to unauthorized persons)
VILLAGE OF BROOKLYN
210 Commercial St.
Brooklyn, WI 53521
Employing Agency
I hereby authorize and empower an employee of the Village of Brooklyn or other authorized representative thereof
bearing this release 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 agencies,
2. Any current or previous landlord or place of residence contracts and contacts,
3. Any banking or financial institutions,
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 or military service contacts,
7. Present employer(s),
8. Any school, college, university or other educational institution,
9. Any individual employed by a past or present employer.
Exceptions to this blanket authorization:
1. Any medical information in the possession of any source named above until subsequent to a conditional
offer of employment (per Americans with Disabilities Act).
2. ______________________________________________________________
3. ______________________________________________________________
This release is executed to authorize the Village of Brooklyn, as a prospective employer, to obtain the above
information. It is understood that said information shall be used only in consideration of my employment and shall not
be further disseminated for any purpose.
Applicant: _______________________________________________________________
(Please Print)
Date: __________________ Date of Birth: ______________ Sex:_______ Race:_______
Address: ________________________________________________________________
Signature: _______________________________________________________________
Witness: ___________________________ Date: _____________________
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Employee Application Form 4 (Village of Brooklyn)

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Completed 14 July 2020

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