EMPLOYMENT APPLICATION
An equal opportunity employer.
PERSONAL
Name
(Last) (First) (Middle)
Address
(Street) (City) (State) (Zip Code)
Telephone
(Area Code)
Email address
Driver's License Number State Expiration Date
Are you a citizen of the United States?
Yes No
JOB INTERESTS/SKILLS
Position(s) applied for Salary Desired
Have you applied for a position here before? Yes No
If yes, when?
Type of employment requested Full Time Part Time Temporary Summer
Date you could begin working Typing Speed (WPM)
Summarize any other special skills or qualifications
EDUCATION
Personnel Department
142 East Main Street
Meriden, CT 06450
Position applied for
Full Time Part Time
Temporary
Summer
If no, please provide a copy of green card or work permit.
Military Experience:
Were you honorably discharged?
Yes
No
Yes
No
TYPE OF
SCHOOL
NAME AND LOCATION COURSE OF STUDY
# OF
YEARS
GRADE
AVERAGE
MAXIMUM
GRADE
DEGREE, DIPLOMA,
CERTIFICATE AND HONORS
RECEIVED
HIGH SCHOOL
COLLEGE OR
UNIVERSITY
OTHER
EDUCATION
OTHER
EDUCATION
EMPLOYMENT HISTORY (LIST MOST RECENT FIRST)
1. Name of Employer
Address
(Street) (City) (State) (Zip Code)
Supervisor and Title
Employed From To
Your Title
Work Performed
Reason for leaving
2. Name of Employer
Address
(Street) (City) (State) (Zip Code)
Supervisor and Title Your Title
Employed From To
Work Performed
Reason for leaving
3. Name of Employer
Address
(Street)
(City) (State) (Zip Code)
Supervisor and Title
Employed From To
Your Title
Work Performed
Reason for leaving
PROFESSIONAL REFERENCES ONLY
In the section below, please do not list friends or relatives unless they have worked with you professionally.
Name Relationship Home Phone Daytime Phone
EMPLOYMENT APPLICATION
An equal opportunity employer.
Personnel Department
142 East Main Street
Meriden, CT 06450
ACKNOWLEDGEMENT
I certify that the answers given by me in this application and/or attached resume are correct to the best of my knowledge. I understand that any
falsification, whether willingly or accidental, may be grounds for disqualification of employment consideration, or dismissal from employment if I am
hired. I authorize the company to contact any and all of the references I have listed above to obtain previous employment information including but
not limited to my personnel file. Further, I release the above mentioned references from any and all liability for any damages that may result from
information collected by this company. I understand that an appropriate medical exam, including drug test, background check and verification of
eligibility to work in the United States must be satisfied for a formal offer to be made.
Applicant's Signature
Date
Printed Name
Do any of your relatives work for the City of Meriden?
Name of Relative
Relationship
Yes
No
If yes please name:
Do you reside with anyone working for the City of Meriden?
Yes No
If yes please name:
Name
Relationship
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