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
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
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.