Fillable Galena-Empl-App-Form-version-06-25-2020 Village of Bremen Employment Application Form

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Galena-Empl-App-Form-version-06-25-2020 Village of Bremen Employment Application Form

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The Galena-Empl-App-Form-version-06-25-2020 Village of Bremen Employment Application Form form is 7 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Village of Galena

BROWSE VILLAGE OF GALENA (OH) FORMS
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Village of Galena, Ohio
P.O. Box 386
109 Harrison Street
Galena, Ohio 43021
PRE-EMPLOYMENT APPLICATION
An Equal Opportunity Employer
Qualified applicants for employment are considered for available positions without regard to race,
religion, color, gender, national origin, age, disability or other legally protected status.
PERSONAL INFORMATION
Name: _______________________________________________________________ SS#: ____________________________
Last First Middle
Address: _______________________________________________________________________________________________
Address City State Zip Code
Position of Interest:
Date Applied: Approximate Date of Availability: _____________________________
Other Telephone: ( ) ______________________
Yes No
Are you prevented from lawful employment in the United States because of immigration or visa status?
NOTE: Proof of citizenship or immigration is required by federal law upon employment.
Have you read the job description of the position for which you are applying? Yes No
Are you capable of performing the essential job functions? Yes No
JOB INTEREST
GENERAL INFORMATION
Have you ever been employed by the Village of Galena? Yes
No
If yes, please provide dates previously worked and position(s) held: ________________________________________________
Have you ever been convicted of a crime, felony or misdemeanor? Yes No
If yes, please provide date, place and charge:
Are you on layoff by an employer, subject to recall?
Yes No
Are you related to any current Village of Galena employee or elected official? Yes No
If yes, disclose name and relationship:
Form Version: 6/25/2020
NOTE: The Village accepts applications only for currently posted positions.
Primary Telephone: (_________) ______________________
Email Address:
High School
Graduated? Yes No
College, University,
Business, Tech,
Vocational, or
Military Academy
Dates Attended (Mo./Yr. to Mo./Yr.):
Degree:
Graduate or
Professional
School
Dates Attended (Mo./Yr. to Mo./Yr.):
Degree:
Are you currently enrolled in an educational program? Yes No If yes, what is your main course of study and where
are you attending?
LICENSES, CERTIFICATIONS, REGISTRATIONS
I possess:
A valid Driver’s License
A valid Commercial Driver’s License
State and Number
Professional/Technical Licenses and Registrations
Type
State Number Expiration Date (if any)
MILITARY SERVICE
Were you in the U.S. Armed Forces: Yes No If yes, what branch? ___________________________________
Dates of Service: From: ___________________ to _____________________ Rank: ______________________________
Technical Specialization: _________________________________________________________________________________
Type of School
Degree
Name & Location of School
Area of Study
or
GED: Yes No
1 2 3 4 5 6 7 8 9 10 11 12
Graduate School:
Indicate the highest level accomplished (elementary and secondary):
Indicate the highest level accomplished: College Undergraduate:
1 2 3 4
1 2 3 4
EDUCATION
From: To:
From:
To:
State and Number
Form Version: 6/25/2020
TRAINING AND OTHER QUALIFICATIONS
Please list any training you feel is relevant to the position for which you are applying:
Subject Area of Training Organization Providing Training Year Training Received
Please use this area to briefly describe any additional information or special qualifications you have for the position for which
you are applying. Please be sure to include any special machinery, office equipment, software, tools, vehicles, or other job-
related items.
EXPERIENCE
Starting on the next page, list your work experience starting with your current/most recent employer. Please include all
employment whether full-time, part-time, seasonal, or temporary during the past ten years. You may include additional
experience beyond the past ten years if you desire and you are encouraged to do so if it is related to the position you are
seeking. You may attach additional pages, if necessary. Please not use a résumé as a substitute for completing this
section; however, you may attach a résumé to supplement the information contained within this employment application.
AWARDS, HONORS, ACHIEVEMENTS, INTERESTS
Please list any awards, honors, achievements, volunteer or community service activities, special interests, hobbies, or any
organizations of which you are/have been a member, and indicate any positions of leadership previously/currently held,
that you feel are relevant to your candidacy for the position for which you are applying.
Form Version: 6/25/2020
Current/Most Recent Employer: ___________________________________________________________________________
Address: ______________________________________________________________________________________________
Mailing Address City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number: (_____)_____________________
Position Held: ______________________________________________________ Salary: ____________________________
Dates of Employment: to Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
The Village of Galena may contact former employers. If you prefer that we do not contact your present employer until
such time as a conditional offer of employment is made, please check this box:
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Mailing Address City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number: (_____)_____________________
Position Held: ______________________________________________________ Salary: ____________________________
Dates of Employment: to Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
Form Version: 6/25/2020
EXPERIENCE (continued)
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Mailing Address City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number: (_____)_____________________
Position Held: ______________________________________________________ Salary: ____________________________
Dates of Employment: to Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Lea
ving:
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Mailing Address City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number: (_____)_____________________
Position Held: ______________________________________________________ Salary: ____________________________
Dates of Employment: to Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
Form Version: 6/25/2020
REFERENCES
Please list at least three individuals, other than relatives, whom we may contact as references regarding your
character, ability, or experience.
Name
Phone Number
(with area code)
Email Address
Type of Reference
(personal, professional,
educational, etc.)
Form Version: 6/25/2020
CERTIFICATION AND STATEMENT OF UNDERSTANDING
READ EACH STATEMENT CAREFULLY BEFORE SIGNING...
I, the undersigned applicant, understand that any false statement made on this application, a résumé or any
other employment document may cause rejection of an application, disqualification from employment
consideration or if discovered at a later date may serve as grounds for discharge after being hired.
Applicant's Initials:
I agree to take any lawful medical examination, drug/alcohol screen, honesty detection/polygraph examination
or written examination required by Village of Galena upon receiving a conditional offer of employment. Further,
I agree to release any and all medical information that may be developed during any pre-employment physical
examination to those who have the need to evaluate such information. I authorize investigation of my credit,
driving record and a comprehensive criminal and employment history review. I also understand that some, if
not all the content of the subject exams, screenings, tests, records reviews and background investigations may
become public record. I release all persons, companies and Village officials conducting any lawful investigation
from any liability.
Applicant's Initials:
I understand that neither this employment application nor an offer of employment constitutes an employment
contract, unless a specific written document to that effect is executed by the Village of Galena Council.
Applicant's Initials:
I agree that any claim or lawsuit relating to my service with Village of Galena must be filed no more than six (6)
months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of
limitations to the contrary.
Furthermore, I agree that this application will be considered active for twelve (12) months from the date filed. If
I am hired, it becomes part of my official employment record.
Applicant's Initials:
I, the undersigned applicant, do solemnly swear and declare that I am the person mentioned herein, and that
all answers or statements made are true to the best of my knowledge.
Signature:
Date:
NOTE: The Village accepts applications only for currently posted positions.
Form Version: 6/25/2020
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Galena-Empl-App-Form-version-06-25-2020 Village of Bremen Employment Application Form

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Completed 12 July 2020

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