Fillable Employment Application 2 (The City of Havre de Grace)

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Employment Application 2 (The City of Havre de Grace)

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Directions: Answer each and every question on all four pages of this application. A resume may be
submitted only to supplement information on the application. Resumes may not be used in place of any
information requested on the application. Write “N/A” in the answer blank if the question is not
applicable to you. Please type or print legibly.
Position
Desired_________________________________________________________ Date_______________
Name__________________________________________________________SSN________________
Last First
Address_____________________________________________Telephone No ___________________
Street Area Home
___________________________________________________________________________________
City State Zip Area Home
To facilitate reference checks, please indicate any other name under which you have been employed.
___________________________________________________________________________________
Are you a minor (under 18 years of age)? Yes_____ No _____
Have you ever been employed with us before? Yes_____ No _____
Are you currently employed? Yes_____ No_____
May we contact your present employer? Yes_____ No_____
On what date would you be available for work? ________________
Are you currently on “lay-off” status and subject to recall? Yes_____No_____
Havre you ever been convicted of a felony in the last 7 years? Yes_____No_____
Conviction will not necessarily disqualify an applicant
from employment.
If yes, please explain. __________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Institution Course of Study Degree Received
High School
Address
College
Address
Graduate School
Address
Circle highest grade completed: 6 7 8 9 10 11 12 GED College: 1 2 3 4 5 6
Have you received any additional training, workshops, short courses, or performed volunteer work, etc. related
to the position?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are you prevented from lawfully becoming employed in this country because of Visa of Immigration Status?
Yes____No____
Proof of citizenship or immigration status will be required upon employment.
EDUCATION
EMPLOYMENT
Start with your present or last job and include your employment history for at least the last ten
years. Please attach an additional sheet if you need more space. Include military experience and
describe any major assignments. Include periods of self employment. Give details of any
supervisory duties you may have had.
If you are still employed, may your present employer be contacted? _____Yes _____No
1. Employed by:_________________________________________________________________
Address:______________________________________________________________________
Supervisor’s Name:_____________________________________________________________
Employed from: (mo/yr)___________________________ To: (mo/yr)____________________
Starting Salary:______________ Final Salary:________________ Hours Per Week:_________
Job Title:_____________________________________________________________________
Duties:_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Reason for leaving:_____________________________________________________________
_____________________________________________________________________________
2. Employed by:__________________________________________________________________
Address:______________________________________________________________________
Supervisor’s Name:_____________________________________________________________
Employed from: (mo/yr)___________________________ To: (mo/yr)____________________
Starting Salary:______________ Final Salary:________________ Hours Per Week:_________
Job Title:_____________________________________________________________________
Duties:_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Reason for leaving:_____________________________________________________________
_____________________________________________________________________________
3. Employed by:__________________________________________________________________
Address:______________________________________________________________________
Supervisor’s Name:_____________________________________________________________
Employed from: (mo/yr)___________________________ To: (mo/yr)____________________
Starting Salary:______________ Final Salary:________________ Hours Per Week:_________
Job Title:_____________________________________________________________________
Duties:_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Reason for leaving:_____________________________________________________________
_____________________________________________________________________________
Have you previously worked for the City of Havre de Grace? Yes_____ No _____
Position: _________________________ Department: ___________________ Dates: __________
List the requirements in the job announcement which you possess: _________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Do you have any experience or qualifications in addition to what you have already listed which
relate to the job applied for? ________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If the position for which you are applying requires the operation of a motor vehicle, please
answer the following:
Do you have a valid driver’s license? Yes____ No____ Class ____________ State_______
Driver’s License Number: ________________________________________
Has your license been revoked or suspended in the last twelve (12) months? ____________
(If yes, please explain) ____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4.. Employed by:_________________________________________________________________
Address:______________________________________________________________________
Supervisor’s Name:_____________________________________________________________
Employed from: (mo/yr)___________________________ To: (mo/yr)____________________
Starting Salary:______________ Final Salary:________________ Hours Per Week:_________
Job Title:_____________________________________________________________________
Duties:_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Reason for leaving:_____________________________________________________________
_____________________________________________________________________________
For clerical/secretarial positions: Typing wpm _______ Shorthand wpm _______
What equipment can you operate? ___________________________________________________
_______________________________________________________________________________
APPLICANT’S STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. In the
event of employment, I understand that false or misleading information given in my application
or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules
and regulations of the City.
Signature_________________________ Date__________
“UNDER MARYLAND LAW, AN EMPLOYER
MAY NOT REQUIRE OR DEMAND, AS A
CONDITION OF EMPLOYMENT,
PROSPECTIVE EMPLOYMENT, OR
CONTINUED EMPLOYMENT, THAT AN
INDIVIDUAL SUBMIT TO OR TAKE A LIE
DETECTOR OR SIMLIAR TEST. AN
EMPLOYER WHO VIOLATES THIS LAW IS
GUILTY OF A MISDEANOR AND
SUBJECT TO A FINE NOT EXCEEDING
$100.00”
Signature Date
(THIS STATEMENT MUST BE ATTACHED TO ALL EMPLOYMENT APPLICATIONS IN
THE STATE OF MARYLAND)
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VOLUNTARY SURVEY
APPLICANT
CHARACTERISTIC
SURVEY
To all applicants:
The city of Havre de Grace has an equal employment program. To find out how
effective our recruitment efforts are in reaching all parts of our population, and to
help us in the validation f our selection methods, we are asking each applicant to
voluntarily give the following information. THIS INFORMATION IN NO WAY
AFFECTS YOU AS AN INDIVIDUAL APPLICANT AND WILL BE
SEPARATED FROM YOUR APPLICATION IMMEDIATELY.
Position Applied For: Zip Code (Home)
Please place the appropriate numbered answer to each question in the block provided on the left.
A.
What sex are you?
1. Male
2. Female
B.
What is your age?
1. Less than 18 years.
2. 18-21 years, inclusive
3. 22-25 years, inclusive
4. 26-39 years, inclusive
5. 40-55 years, inclusive
6. 56-69 years, inclusive
7. 70 years or over.
C. Of which racial/ethnic group do you consider yourself a member?
D. How did you learn about the job for which you are now applying?
1. White
2. Black
3. Asian/Pacific Islander
4. Hispanic
5. American Indian or
Alaskan Native
1. City of Havre de Grace Personnel Dept.
2. Other City Agency
3. City employee
4. Friend
5. Newspaper or periodical
________________________
Name of Publication
6. Job service listing
7. Other employment service
8. Television
9. Radio
10. School
11. Church
12. Community Organization
_____________________
Name of Organization
E.
Are you a veteran of the U.S. Military?
1. Yes
2. No
F.
Are you mentally or physically disabled?
1. Yes
2. No
EMPLOYMENT STATEMENT
CITY OF HAVRE DE GRACE
Date: _______________________
1. The background information supplied by an applicant for a position opening will
be checked by the City of Havre de Grace or an outside reference checking
ser vice to ensure the accuracy of the data furnished and the past performance record
of candidate.
2. I authorize the City of Havre de Grace to make sure such investigations and inquiries
as may be necessary in arriving at an employment decision. I hereby release
employers, schools, or persons from all liability in responding to inquiries in
connection with my application for employment.
3. I should not resign my current employment until I have received a formal offer of
employment by the City of Havre de Grace and have successfully passed the pre-
employment physical and drug/alcohol screening test.
4. The City of Havre de Grace retains the right to hire the person who appears to
best fit its needs at this time. There will not be an explanation (unless specifically
required by law) as to what factors went into this decision.
5. The answers given to the City of Havre de Grace representatives are true and
complete to the best of my knowledge. In the event of employment, any
significant misstatements or omissions later discovered in my background may be
cause for my dismissal from employment with the City of Havre de Grace.
_________________________________
Candidate’s Signature
_________________________________
Print Full Name
_________________________________
Social Security Number
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Employment Application 2 (The City of Havre de Grace)

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Completed 14 July 2020

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