Rev Date 05/11/2017 Page 1 of 6
CITY OF LEBANON, NEW HAMPSHIRE
51 North Park Street
Lebanon, New Hampshire 03766
APPLICATION FOR EMPLOYMENT
Individuals requiring an accommodation in order to apply for a position or participate in the hiring
process should timely contact Human Resources at 603-448-0683.
Please print or type all responses and complete the application in full. Incomplete applications may result in
disqualification from consideration. Additional sheets may be attached for any section, as necessary
GENERAL INFORMATION
Date of Application: _______________(mm/dd/yyyy)
Position Applied For: ______________________________________
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Name:_______________________________________________________
Address: _____________________________________________________
City:____________________ State:_______________ Zip Code:_______
Home Phone:______________ (xxx-xxx-xxxx) Mobile Phone:____________ (xxx-xxx-xxxx)
Work Phone:______________ (xxx-xxx-xxxx) May we contact you at work? Yes [ ] No [ ]
Email Address:_________________________________
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Have you ever been employed by the City of Lebanon? Yes [ ] No [ ]
If answered ‘yes’ above, provide details below:
Title
of Position Held and Department: ___________________________________________
Dates of Employment (Start/End Dates mm/dd/yyyy): [S]____________ [E]____________
Rea
son(s) for Leaving:____________________________________________________________
(Attach additional sheets as necessary)
*****
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If you are under 18 years of age, can you provide proof of your eligibility to work? Yes [ ] No [ ]
In a
ccordance with the Immigration Reform and Control Act, can you provide proof that you are eligible to
work in the United States? Yes [ ] No [ ]
*****
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List any relatives currently working for the City of Lebanon; attach additional sheets as necessary.
Name
Position & Department
Relationship
Rev Date 05/11/2017 Page 2 of 6
EDUCATION
Did you receive a high school diploma or GED? Yes [ ] No [ ]
Post Graduate Education:
Education
Institution Name and
Address
No. of Years
Completed
Degree Conferred &
Course(s) of Study (e.g.,
BA, English)
Undergraduate
College/University
Graduate
College/University
Professional/
Technical
Other
SKILLS, PROFESSIONAL LICENSES AND CERTIFICATIONS
Please list any other relevant licenses, certifications, knowledge and experience:
Professional license(s) or certification(s):
____________________________________________________________________________
____________________________________________________________________________
Equipment and/or machinery operation:
____________________________________________________________________________
____________________________________________________________________________
Software and/or Computers:
____________________________________________________________________________
____________________________________________________________________________
Other:
____________________________________________________________________________
____________________________________________________________________________
MILITARY EXPERIENCE
Have you served in the Armed Forces? Yes [ ] No [ ]
If ‘yes,’ what branch? ______________________ Rank at Discharge: ______________________
Describe any training received which is relevant to the position for which you are applying (attach additional
sheets as necessary):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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EMPLOYMENT HISTORY
List all positions held, starting with your most recent position. This section must be completed in full, even if
you are providing a resume. Do not state ‘see resume.’ Attach additional sheets as necessary.
For applicants with no employment history, please check here: N/A [ ]
Current Position/Most Recent Position
Company:_________________________________________
Address:__________________________________________
City:_______________________ State:_______________ Zip Code:__________
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Position Held:__________________________ Dates of Employment:
From:___________ To:____________
mm/dd/yyyy mm/dd/yyyy
(or ‘Present’)
Ending Salary: $____________
Job Duties:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Reason(s) for leaving: ________________________________________________________
Supervisor’s Name:________________________________ Telephone:____________________
(xxx-xxx-xxxx)
May we contact your present employer? Yes [ ] No [ ]
EMPLOYMENT HISTORY, Continued
Company:_________________________________________
Address:__________________________________________
City:_______________________ State:_______________ Zip Code:__________
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Position Held:__________________________ Dates of Employment:
From:___________ To:____________
mm/dd/yyyy mm/dd/yyyy
Ending Salary: $____________
Job Duties:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
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Reason(s) for leaving: ________________________________________________________
Supervisor’s Name:________________________________ Telephone:____________________
(xxx-xxx-xxxx)
Rev Date 05/11/2017 Page 4 of 6
EMPLOYMENT HISTORY, Continued
Company:_________________________________________
Address:__________________________________________
City:_______________________ State:_______________ Zip Code:__________
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Position Held:__________________________ Dates of Employment:
From:___________ To:____________
mm/dd/yyyy mm/dd/yyyy
Ending Salary: $____________
Job Duties:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
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Reason(s) for leaving: ________________________________________________________
Supervisor’s Name:________________________________ Telephone:____________________
(xxx-xxx-xxxx)
EMPLOYMENT HISTORY, Continued
Company:_________________________________________
Address:__________________________________________
City:_______________________ State:_______________ Zip Code:__________
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Position Held:__________________________ Dates of Employment:
From:___________ To:____________
mm/dd/yyyy mm/dd/yyyy
Ending Salary: $____________
Job Duties:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
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Reason(s) for leaving: ________________________________________________________
Supervisor’s Name:________________________________ Telephone:____________________
(xxx-xxx-xxxx)
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CRIMINAL HISTORY
Have you ever been convicted of a crime that has not been annulled by a court, or are you currently charged
with or under investigation for a criminal matter? Yes [ ] No [ ]
If “Yes,” please explain in full below (a current criminal charge/investigation and/or conviction will not
automatically disqualify you from employment). Attach additional sheets as necessary.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
DRIVER INFORMATION
(Complete if Position Requires a Driver’s License or CDL)
List all current and valid driver licenses held (attach additional sheets as necessary):
Issuing State:________________________ Type:______________ Expiration Date:________
(e.g., Operator, CDL-B)
Issuing State:________________________ Type:______________ Expiration Date:________
(e.g., Operator, CDL-B)
If a CDL holder, list endorsements, if any: _______________________________________________
____________________________________________________________________________
Provide motor vehicle accident record for the last 7 years. Attach additional sheets as necessary.
Date of Accident
Nature of Accident (e.g., head-on, rear-end, etc.)
Indicate all traffic convictions for the last 7 years (other than parking violations) and dates of all license
suspensions or forfeitures for the last 7 years. Attach additional sheets as necessary.
Location
Date
Description
PROFESSIONAL REFERENCES
List 3 professional references, including at least 2 direct supervisors with personal knowledge of your work.
For applicants with no employment history, please check here: N/A [ ]
Name and Position Title
Company and Address
Telephone Number
Email Address
Rev Date 05/11/2017 Page 6 of 6
ADDITIONAL INFORMATION
Please use this section to provide any additional information you feel would be helpful when evaluating your
application.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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How did you learn of the employment opportunity for which you are applying?
City Website [ ] City Employee [ ]
City Newsletter [ ] Other [ ]
City LebAlert [ ] List: _____________________
Newspaper Ad [ ]
Internet Website(s) [ ]
List:_____________________________
CERTIFICATION AND AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING
I CERTIFY that all entries on this application for employment and attachments are true and complete and I
agree and understand that any falsification of information herein, material half-truths, material misstatements
or omissions, regardless of their time of discovery, may cause forfeiture on my part to any employment with the
City of Lebanon. I understand that all information on this application is subject to verification and I consent to
references and former employers and educational institutions listed being contacted regarding this application.
I AUTHORIZE the City of Lebanon to obtain any information from schools, residential management agents,
employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but
is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary,
and conviction records not annulled by a court. Further, I hereby authorize all references, persons, schools, my
current employer (if applicable), and previous employers and organizations named in this application (and
accompanying resume and other documents supplied by me, if any) to provide the City of Lebanon any relevant
information that may be required to arrive at an employment decision. I understand that the information
release is for the City of Lebanon’s use only.
I RELEASE any individual, including record custodians, from any and all liability for damages of whatever
kind or nature which may, at any time happen to me as a result of compliance, or any attempts to comply with
this authorization.
I FURTHER ACKNOWLEDGE that as a condition of employment, I may be required to undergo a pre-
employment background check and/or examination, which may include, but not be limited to, a criminal
history check, driver record check, and/or physical. I also acknowledge that in compliance with federal law, if I
am hired by the City of Lebanon, I will be required to verify my identity and eligibility to work in the United
States and to complete the required employment eligibility verification document form.
______________________________________ ____________________
Applicant’s Signature Date
(mm/dd/yyyy)
The City of Lebanon is an Equal Opportunity Employer