Fillable Form 1340 (City of Beavercreek)

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Form 1340 (City of Beavercreek)

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The Form 1340 (City of Beavercreek) form is 5 pages long and contains:

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  • 29 check-boxes
  • 196 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Beavercreek

BROWSE CITY OF BEAVERCREEK (OH) FORMS

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Human Resources Department, 1368 Research Park Drive, Beavercreek, Ohio 45432
Phone: (937) 320-7387 Fax: (937) 427-5545 Email: hr@beavercreekohio.gov
Positions Desired: ______________________________ Salary Expected: __________/ Hour
Full Time
Part Time Seasonal Internship
Application Date: ____________________ Date Available for Work: ____________________
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable
accommodation during the application and/or interview process should notify a representative of the Human Resources
Department.
Applications are kept on file for one year. Please keep a copy for your files.
Please answer all questions accurately and completely. Incomplete applications may be disqualified.
By signing this application, you are affirming that all information you provide is accurate and complete.
How did you learn about us/this job? (Check One)
Advertisement Friend/Relative City/Employee City Website Walk-in Other
Applicant Information
Name: _____________________________________________ Social Security No.: ____________________
First Name Middle Initial Last Name
Address: _________________________________________________________________________________________
City State Zip Code
Telephone No.: (_____)_______________ Work Phone No.: (_____)_______________
Cell/Other: (_____)_______________
E-mail Address: _______________________________________________
If necessary, best time to call you at home: ___________ a.m.
p.m. Anytime
May we contact you at work? Yes No
General Information
Are you now, or have you ever been employed with the City of Beavercreek? Yes No
If yes, please give date(s) and position(s). ______________________________________________________________
Do you have relatives employed by the City? Yes
No
If yes, please give name, relationship, and department. ____________________________________________________
Are you at least 18 years old? Yes
No
If you are under 18 and it is required, can you furnish a work permit? Yes No
Are you lawfully eligible to work in the United States? Yes No
APPLICATION FOR
EMPLOYMENT
✔
✔
✔
✔
✔
✔
Do you have a valid Ohio Drivers License? Yes No Operator’s CDL Endorsements: Yes No
Drivers License No.: ____________________ Expiration: ____________________
Have you ever had your license suspended? If yes, please explain.
Note: You may be disqualified from employment in certain positions with the City of Beavercreek if the results of the
criminal background check reveal a particular criminal history.
Employment History
In this section, please describe the duties you have performed in previous positions, which demonstrate that you have the
knowledge, skills, and abilities to perform the duties of the job for which you are applying.
Begin with your most recent job or assignment first and list each job separately, extending for a period of 10 years.
Please explain all periods of unemployment. Additional pages of work history may be attached, if necessary.
A resume is not a substitute for this section of the application.
May we contact this employer? Yes No Telephone No.: (_____)_______________
Employer: ___________________________________ Position Title: ___________________________________
Address: _________________________________________________________________________________________
City State Zip Code
Starting Salary: __ Ending Salary: __ Start Date: __ End Date: __
Supervisor’s name and title: __________________________________________________________________________
Duties & Responsibilities:
Reason for leaving: _________________________________________________________________________________
____ _____ ___ ______ ___ ___ ______ __ ___ ____ _
May we contact this employer? Yes No Telephone No.: (_____)_______________
Employer: ___________________________________ Position Title: ___________________________________
Address: _________________________________________________________________________________________
City State Zip Code
Starting Salary: __ Ending Salary: __ Start Date: __ End Date: __
Supervisor’s name and title: __________________________________________________________________________
Duties & Responsibilities:
Reason for leaving: _________________________________________________________________________________
____ _____ ___ ______ ___ ___ ______ __ ___ ____ _
May we contact this employer? Yes No Telephone No.: (_____)_______________
Employer: ___________________________________ Position Title: ___________________________________
Address: _________________________________________________________________________________________
City State Zip Code
If additional space is required, please enclose an attachment.
✔
✔
✔
✔
Starting Salary: __ Ending Salary: __ Start Date: __ End Date: __
Supervisor’s name and title: __________________________________________________________________________
Duties & Responsibilities:
Reason for leaving: _________________________________________________________________________________
____ _____ ___ ______ ___ ___ ______ __ ___ ____ _
May we contact this employer? Yes No Telephone No.: (_____)_______________
Employer: ___________________________________ Position Title: ___________________________________
Address: _________________________________________________________________________________________
City State Zip Code
Starting Salary: __ Ending Salary: __ Start Date: __ End Date: __
Supervisor’s name and title: __________________________________________________________________________
Duties & Responsibilities:
Reason for leaving: _________________________________________________________________________________
____ _____ ___ ______ ___ ___ ______ __ ___ ____ _
Education and Training
Check the highest school grade completed.
High School: 9
10 11 12 College: 13 14 15 16 17 18 19
Name of School
Address
Courses of Study
Credits Completed
Semester/Quarter
Hours
Degree or
Certificate
Earned
List any job-related schools attended or vocational training received. (If additional space is required, please list separately
as an attachment.)
Name of School
Date(s)
Type of Training
List any professional licenses or certificates.
Title of license or certificate
Number
Issuing Agency
Date Issued/Date of Expiration
✔
✔
Special Skills:
Typing __________ (wpm) Calculator Word Excel Outlook Access
Other (Specify):
Heavy Equipment Tools:
References (Relatives are not acceptable references)
Name & Title
Occupation
Address (Include City, State & Zip Code)
Phone No.
Certification of Information, Authorization & Release
ALL APPLICANTS: Please read the following and address any questions to the Human Resources Representative before signing.
I affirm that the information provided on this application and any accompanying documents is true and complete to the best of my knowledge. I
understand that, if I am employed by the City of Beavercreek, its subsequent discovery of any false statements, significant omissions, or
misleading information provided by me in connection with this application may result in termination of my employment.
I authorize investigation of all statements contained in this application and any accompanying documents as may be necessary in arriving at an
employment decision. I also understand that the city will perform a background check on me. I authorize this background check and also
authorize all personnel, schools, companies, corporations, and law enforcement agencies to supply the City of Beavercreek with any and all
pertinent information they may have about me. I release the same from any liability in connection with their provision of such information.
I understand that the City of Beavercreek may be required to submit/release this application and its accompanying documents, in response to a
public records request. I release the City of Beavercreek and its agents, from any liability that may result from submitting/releasing such
information.
I acknowledge that the City of Beavercreek may require, as a condition of any offer of employment that is made, or for continued employment,
that I undergo a medical exam, drug testing, or alcohol testing, and I consent and agree to any such exam, if required now or in the future. I
understand that a satisfactory drug test result is a condition of employment with the City.
I understand that federal law prohibits the employment of unauthorized aliens and requires satisfactory proof of employment authorization and
identity. I further understand that all persons hired must submit satisfactory proof of employment authorization and identity. I agree to have
necessary documents promptly available for inspection as required by law.
I understand that this application is not a contract of employment. If employed, I understand that I will be required to abide by the City of
Beavercreek’s Rules and Regulations. I understand that the City of Beavercreek follows an “employment at will” policy, in that I or the City may
terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot
be changed verbally or in writing, unless the change is specifically authorized in writing by the City Manager.
I understand that the City of Beavercreek is an Equal Opportunity Employer.
By signing below, I acknowledge that I have read and understand the above notice, and I authorize the pre-employment checks and tests listed
therein.
______________________________________ ______________________________
Signature of Applicant Date
EQUAL EMPLOYMENT OPPORTUNITY STATISTICAL SUPPLEMENT
Applicants for employment are requested, but not required, to provide the following supplementary
data. Availability of this data assists in the maintenance of an Equal Employment Opportunity
Program. Please DO NOT place your name on this form.
THIS FORM IS VOLUNTARY AND DOES NOT AFFECT YOUR EMPLOYMENT STATUS.
Position: ______________________________________________________________________
Full-time Part-time Seasonal
Date of Application: ______________________
Race or Ethnic Origin: Caucasian African-American Hispanic
Asian American Indian Other
Sex: M F
PLEASE DO NOT PLACE YOUR NAME ON THIS FORM.
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Form 1340 (City of Beavercreek)

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Completed 14 July 2020

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