APPLICATION FOR EMPLOYMENT
Town of Lexington, Massachusetts
Thank you for your interest in employment with the Town of Lexington. The Town is an Equal
Opportunity/Affirmative Action Employer. We assure you that your opportunity for employment with the Town
will be based only on your merit, without regard to race, religion, sex, age, national origin or disability.
PLEASE NOTE: The Town accepts applications for advertised positions only. Applications must be returned to
the address below by the advertised deadline for consideration.
INSTRUCTIONS: Each question should be fully and accurately answered. Please fill out the form, then print,
sign and mail to:
TOWN OF LEXINGTON, MA
HUMAN RESOURCES
LEXINGTON MA 02420-3801
A separate application must be submitted for each position for which you are applying.
GENERAL
Position applying for: __________________________________ Date of application: __________ (mm/dd/yyyy)
Referral source:
Newspaper Ad Online Ad Town of Lexington Employee Relative Employment Agency
School Website Town Website Other_________________________________
Name of source (if applicable): ____________________________
Date available for work: __________ (mm/dd/yyyy)
PERSONAL
Name: (first) __ (middle) ______________ (last) ______________________________
Address: (Street) _____________________________________________________________________________
(City) _________ (State) ________________ (Zip)__________
Are you age 18 or older
? Yes
No
If no list date of birth: _____
Have you worked for the Town of Lexington before? Yes No
If yes: Department: _____
Dates of service: From: __________ To: ______ (mm/dd/yyyy)
Were you in the U.S. Armed Forces? Yes No
If yes, which branch? ___
Dates of service: From: __________ To: ______ (mm/dd/yyyy)
Do you have a family member working for the Town? Yes No
If yes, please list their name and department:
Name: __________
Department: _____
____________________
_______________________________
_____
_________
____
__________
____
______ ___________
____________
____________
_______________ ____________
___
______
___________ ___
Phone: Home ______________ Cell ______________ Email: _______________________________________
(mm/dd/yyyy)
PRESENT AND PRIOR EMPLOYMENT
Please list below employers in consecutive order with present or most recent employer listed FIRST. Account
for all periods of time between employment.
A resume may be attached but DO NOT refer to the resume when completing all sections of this application. Use
additional sheets if necessary.
PROVIDING SALARY INFORMATION FOR PRIOR POSITIONS IS OPTIONAL.
MOST RECENT EMPLOYMENT
May we contact this employer? Yes No
EMPLOYER
Name: _______
Street Address: ___
City: ______
State: _______ Zip: __________
Phone: __
Type of Business: ______
Supervisor: ____
POSITION
Title: __
______
_____
______
____
__
_______
______
______
_____
___
___
____
___
________
______
_______
___
__
____
___
______
_____
______
___
___
____
______
___
____
______
____
___
__
___
___
_____
______
_
___
___
__
___
_
___
__________
___
___
____
___
___
____
___
____
Employment Dates:
From: __________ To: __________ (mm/dd/yyyy)
Base Annual Salary (without overtime): Beginning $ _______ Ending $ _______
If applicable, typical amount of overtime annually: $ _______
Description of Duties: _________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________________
Reasons for leaving or seeking other employment: __________________________________________________
___________________________________________________________________________________________
May we contact this employer? Yes No
PREVIOUS EMPLOYMENT
EMPLOYER
Name: _______
Street Address: ___
City: ______
State: _______ Zip: __________
Phone: ___
Type of Business: ______
Supervisor: ____
POSITION
Title: __
___
__
______
____
___________
___
___
______
______
___
___
____
____
________
______
______
___
__
____
___
______
_____
______
___
___
____
______
___
____
___
____
___
___
___
___
___
___
_
____
___
___
___
___
_
__
___
___
____
__
___
___
___
___
____
___
___
__
___
___
Employment Dates:
From: __________ To: __________ (mm/dd/yyyy)
Base Annual Salary (without overtime): Beginning $ _______ Ending $ _______
If applicable, typical amount of overtime annually: $ _______
Description of Duties: _________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________________
Reasons for leaving or seeking other employment: __________________________________________________
___________________________________________________________________________________________
No May we contact this employer? Yes
PREVIOUS EMPLOYMENT
EMPLOYER
Name: _______
Street Address: _____
City: ______
State: _______ Zip: __________
Phone: _______
Type of Business: ______
Supervisor: ____
POSITION
Title: __
___
___
______
__________
__
_______
______
______
______
___
___
____
______
________
______
______
___
______
__
___
______
_____
______
____
______
______
______
_______
______
______
_
___
____
___
______
______
______
___
__
____
___
__
___
_____
___
Employment Dates:
From: __________ To: __________ (mm/dd/yyyy)
Base Annual Salary (without overtime): Beginning $ _______ Ending $ _______
If applicable, typical amount of overtime annually: $ _______
Description of Duties: _________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________________
Reasons for leaving or seeking other employment: __________________________________________________
___________________________________________________________________________________________
May we contact this employer? Yes No
PREVIOUS EMPLOYMENT
EMPLOYER
Name: _______
Street Address: _____
City: ______
State: _______ Zip: __________
Phone: _______
Type of Business: ______
Supervisor: ____
POSITION
Title: __
___
___
______
__________
__
_______
______
______
______
___
___
____
______
________
______
______
___
______
__
___
______
_____
______
____
______
______
______
_______
______
______
_
___
____
___
______
______
______
___
__
____
___
__
___
_____
___
Employment Dates:
From: __________ To: __________ (mm/dd/yyyy)
Base Annual Salary (without overtime): Beginning $ _______ Ending $ _______
If applicable, typical amount of overtime annually: $ _______
Description of Duties: _________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________________
Reasons for leaving or seeking other employment: __________________________________________________
___________________________________________________________________________________________
Have you ever been terminated or asked to resign from any position? Yes No
If yes, which position? ___________________________________________
Explain:___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
SPECIAL SKILLS, APTITUDES, AND OTHER QUALIFICATIONS
Do you have experience with the following software?
Word Processing: Yes No
Spreadsheet: Yes
No
Database: Yes
No
If yes, name of application: _______________________
Driver’s license #: ___________________ State: __ Expires: __________ (mm/dd/yyyy) Class: __________
List any machinery or heavy equipment that you have operated efficiently:_____________________________
_________________________________________________________________________________________
Special qualifications and skills (licenses or certificates, memberships in professional organizations, etc.)
_______________________________________________________________________________________
_______________________________________________________________________________________
EDUCATION
Graduated?
No
No
No
High School
Name: _________________________________________________________________
Address: _______________________________________________________________
Vocational School
Name: __________________________________________________________________
Address: ________________________________________________________________
Major (s): ______________________________________________________________________
Degree: ________________________________________________________________________
Undergraduate College
Name:
__________________________________________________________________
Address: ________________________________________________________________
Major (s): ______________________________________________________________________
Degree: ________________________________________________________________________
Graduate C
ollege
Name: __________________________________________________________________
Address: ________________________________________________________________
Major (s): ______________________________________________________________________
Degree: ________________________________________________________________________
Additional education and/or vocational, technical or military training relevant to the position:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Yes
Yes
Yes
Yes
No
REFERENCES
Please provide three (3) PROFESSIONAL references. References should be former supervisors who can
comment on your past job performance. You will be notified before references are contacted.
Name and occupation Address Phone
1) __________________________________________________________________________________
2) __________________________________________________________________________________
3) __________________________________________________________________________________
OTHER INFORMATION
Are you able to provide documented proof of U.S. citizenship or valid work permit as required upon employment
to work in the United States? Yes No
Please review the functions of the position as outlined in the job description. Are you able to perform all of the
essential duties of the position for which you are applying? Yes No
APPLICANT’S CERTIFICATION
I certify under penalty of perjury that the statements made in this application are true and correct. I authorize the
Town of Lexington to investigate all statements made as part of this application and to secure any necessary
information from all prior employers, references, academic institutions and law enforcement agencies. I release
all of those persons, employers, references, academic institutions and law enforcement agencies from any and all
liability arising from their giving and receiving information about my employment history, academic credentials,
qualifications or criminal record. I understand that any false answers, or statements or misrepresentations by
omission made by me as part of my application will be sufficient for rejection of my application or for my
immediate dismissal should one be discovered after I am employed. I understand that federal law prohibits the
employment of unauthorized aliens and that the Town has an obligation to make sure all employees, regardless of
citizenship or national origin, are allowed to work in the United States. All persons hired must submit proof of
citizenship, permanent resident status or employment authorization in the form of an Employment Authorization
Document. I understand that failure to submit satisfactory proof of identity and employment authorization will
result in a denial of employment. I understand that my employment with the Town, should I be hired, is a
voluntary one. Nothing in this employment application, in the Town’s statements of personnel guidelines, or in
my communication with any Town employee or official is intended to create an employment contract between the
Town and me. I acknowledge that employment is not guaranteed for a definite period of time and that some
positions regarded as part-time and/or temporary are paid for actual hours worked and are not entitled for benefits
offered to full-time positions (except FICA and Workers’ Compensation).
There is nothing to keep me from fulfilling the duties of the job for which I have applied.
Signature: __________________________________________ Date: __________________________
The Civil Rights Act of 1964 prohibits discrimination in employment practice because of race, color, religion, sex or national
origin. PL90-202 prohibits discrimination because of age.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome