Employment Application
Human Resources Department
Applicant Information
Date _____________
Name __________________________________________________________________
Last First M.I.
Address ________________________________________________________________
Street City/Town State Zip
Phone __________________ Email _______________________________________
Position Applied For _______________________________________________________
Where did you learn about this position? ______________________________________
Are you eligible to work in the United States?
0
Yes
0
No
Have you ever worked for the City of Winooski?
0
Yes
0
No
If yes, when? __________________________________________
Does this position require a CDL?
0
Yes
0
No
Do you have any relatives that work for this municipality?
0
Yes
0
No
If yes, who? ___________________________________________
Education
Name of High School __________________________________________________
Address __________________________________ Number of Years attended ____
Did you Graduate?
0
Yes
0
No Degree ________________________
Name of College ______________________________________________________
Address __________________________________ Number of Years attended ____
Did you Graduate?
0
Yes
0
No Degree ________________________
Name of Other ________________________________________________________
Address __________________________________ Number of Years attended ____
Did you Graduate?
0
Yes
0
No Degree ________________________
Employment
Name of Employer _______________________________ Job Title ______________
Address ________________________________________ Phone ________________
Dates of Employment: From ___/___/___ through ___/___/___
Responsibilities _______________________________________________________
Name of Supervisor _____________________ Reason for Leaving _____________
May we contact this employer and supervisor for a reference?
0
Yes
0
No
Name of Employer _______________________________ Job Title ______________
Address ________________________________________ Phone ________________
Dates of Employment: From ___/___/___ through ___/___/___
Responsibilities _______________________________________________________
Name of Supervisor _____________________ Reason for Leaving _____________
May we contact this employer and supervisor for a reference?
0
Yes
0
No
Name of Employer _______________________________ Job Title ______________
Address ________________________________________ Phone ________________
Dates of Employment: From ___/___/___ through ___/___/___
Responsibilities _______________________________________________________
Name of Supervisor _____________________ Reason for Leaving _____________
May we contact this employer and supervisor for a reference?
0
Yes
0
No
Professional References List 3
1. Full Name ________________________ Company ___________________ Phone ______________
Relationship ___________________________ Address ______________________________________
2. Full Name ________________________ Company ___________________ Phone ______________
Relationship ___________________________ Address ______________________________________
3. Full Name ________________________ Company ___________________ Phone ______________
Relationship ___________________________ Address ______________________________________
Additional Information
Please list any other relevant certifications, skills, education, training or licenses you possess:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Military Service
Branch ______________________ From _________ To ______
Rank at Discharge ______________________
Military Experience Relevant to the position applied for:
______________________________________________________________________________
______________________________________________________________________________
Non-Discrimination Statement
It is the policy of this Municipality to provide equal opportunity to apply to all applicants and employees
without regard to race, color, religion, sex, national origin, ancestry, place of birth, age, marital status,
pregnancy status, genetic information, physical or mental condition, HIV status, veteran status, sexual
orientation, gender identity, or other category protected by state or federal law. No question is asked on
this application or during the application process for the for the purpose of excluding any applicant due to
the aforementioned protected categories or other category protected by law.
Di
sclaimer and Signature
Al
l information provided by me is true and correct to the best of my knowledge. I understand omissions or
misrepresentations may be cause for rejection or, if employed, may be cause for immediate dismissal. I
hereby authorize any former employer, person, firm, corporation or educational institution listed heron
including this municipality to answer any and all questions, provide documents and agree to hold all
persons harmless for giving any and all truthful information within their knowledge or records. I understand
this is a preliminary application and not a contract for employment. Furthermore, in the event I am hired,
my employment shall be completely voluntary and may be terminated at will at any time for any non-
discriminatory reason upon notice by either myself or the municipality. I agree to comply with all
reasonable rules of the municipality and condition of employment.
Signature ________________________________________ Date _______________