Fill - Free fillable Form 529 CITY OF LEBANON, NEW HAMPSHIRE PDF form

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: ______________________________________

********************************************************************************************************

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:_________________________________

*******************************************************************************************************

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)

*****

***************************************************************************************************

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 [ ]

*****

***************************************************************************************************

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

Did You

Graduate?

No. of Years

Completed

Degree Conferred &

Course(s) of Study (e.g.,

BA, English)

Undergraduate

College/University

Yes [ ] No [ ]

Graduate

College/University

Yes [ ] No [ ]

Professional/

Technical

Yes [ ] No [ ]

Other

Yes [ ] No [ ]

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):

____________________________________________________________________________

Rev Date 05/11/2017 Page 3 of 6

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:__________

********************************************************************************************************

Position Held:__________________________ Dates of Employment:

From:___________ To:____________

mm/dd/yyyy mm/dd/yyyy

(or ‘Present’)

Ending Salary: $____________

Job Duties:____________________________________________________________________

____________________________________________________________________________

********************************************************************************************************

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:__________

********************************************************************************************************

Position Held:__________________________ Dates of Employment:

From:___________ To:____________

mm/dd/yyyy mm/dd/yyyy

Ending Salary: $____________

Job Duties:____________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

********************************************************************************************************

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:__________

********************************************************************************************************

Position Held:__________________________ Dates of Employment:

From:___________ To:____________

mm/dd/yyyy mm/dd/yyyy

Ending Salary: $____________

Job Duties:____________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

********************************************************************************************************

Reason(s) for leaving: ________________________________________________________

Supervisor’s Name:________________________________ Telephone:____________________

(xxx-xxx-xxxx)

EMPLOYMENT HISTORY, Continued

Company:_________________________________________

Address:__________________________________________

City:_______________________ State:_______________ Zip Code:__________

********************************************************************************************************

Position Held:__________________________ Dates of Employment:

From:___________ To:____________

mm/dd/yyyy mm/dd/yyyy

Ending Salary: $____________

Job Duties:____________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

********************************************************************************************************

Reason(s) for leaving: ________________________________________________________

Supervisor’s Name:________________________________ Telephone:____________________

(xxx-xxx-xxxx)

Rev Date 05/11/2017 Page 5 of 6

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.

____________________________________________________________________________

********************************************************************************************************

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

Fill Online, Printable, Fillable, Blank Form 529 CITY OF LEBANON, NEW HAMPSHIRE Form

Related forms

Fillable Form 529 CITY OF LEBANON, NEW HAMPSHIRE

Fill Online, Printable, Fillable, Blank Form 529 CITY OF LEBANON, NEW HAMPSHIRE Form

Related forms

First 20 documents completely FREE!