Fillable Mu City Hall, Government Plaza 38 Hawley Street, (City of Binghamton)

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Mu City Hall, Government Plaza 38 Hawley Street, (City of Binghamton)

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BROWSE CITY OF BINGHAMTON (NY) FORMS

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THE CITY OF BINGHAMTON IS AN EQUAL OPPORTUNITY EMPLOYER WITH A COMMITMENT
TO WORKFORCE DIVERSIFICATION.
Mu
nicipal Civil Service Commission Action Taken _____________________
City Hall, Government Plaza
38 Hawley Street, 4
th
Floor Referred To ______________________
Binghamton, NY 13901
http://www.binghamton-ny.gov
Date ______________________
Federal, State and Local laws prohibit discrimination in employment because of race, color, religion, national origin, sex,
age, disability, marital status, criminal record, sexual orientation or veteran status.
DIRECTIONS: Please print in ink or type. Please answer all questions completely. An incomplete application may
result in disqualification. A resume may not be substituted.
Position for which you are applying: ____________________________________________________________________
NAME: ____________________________________________________________________________________________
ADDRESS: _________________________________________________________________________________________
(Number) (Street) (City)
EMAIL ADDRESS:___________________________________________________________________________________
TE
LEPHONE: __________________________________
1. How long have you lived in Binghamton? Year(s) ___________ Month(s) _______
2. Are you legally eligible for employment in the USA? _________ Yes __________ No
3. If you are under the age of 18 years, state your birth date: __________________
4. If a motor vehicle is required for a position, please circle the license you presently possess:
Class A B C D E (N.Y. State) C.D.L. Class ______________
5. Check appropriate answer for each question:
A. Were you ever dismissed or discharged from any employment for reasons other than lack of work or
funds? ______YES _______NO
B. Did you ever resign from any employment rather than face dismissal? _____YES _____NO
C. Have you ever been convicted of any crime? ________YES ______NO
D. Are you now under charges for any crime? ________YES ______NO
If you answered “YES” to any of the questions in #5, give specifics under REMARKS on the last page of this application.
None of the above circumstances represents an automatic bar to employment. Each case is considered and evaluated
on individual merits in relation to the duties and responsibilities of the position for which you are applying.
6. Veteran of the U.S. Armed Forces? _______ Yes _______ No Dates: ____________Branch_____________
7. EDUCATION: Please state highest grade completed: ___________________________________
Gr
ad? Course of Study # Credits
Name & Location Y or N Degree & Date Completed
HIGH SCHOOL OR GED
COLLEGE
OTHER SCHOOLS OR SPECIAL COURSES
THE CITY OF BINGHAMTON IS AN EQUAL OPPORTUNITY EMPLOYER WITH A COMMITMENT
TO WORKFORCE DIVERSIFICATION.
8. EMPLOYMENT
Describe your employment history as completely as possible, starting with your most recent employer. Please include all relevant
skills and experience.
EMPLOYER ______________________________________________ TELEPHONE NUMBER _________________________________
ADDRESS ________________________________________________ DATES EMPLOYED ___________________________________
JOB TITLE _______________________________________________ SUPERVISOR’S NAME ________________________________
REASON FOR LEAVING ________________________________________________________________________________________
DESCRIBE YOUR DUTIES AND WORK EXPERIENCE:__________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
EMPLOYER ______________________________________________ TELEPHONE NUMBER _________________________________
ADDRESS ________________________________________________ DATES EMPLOYED ___________________________________
JOB TITLE _______________________________________________ SUPERVISOR’S NAME ________________________________
REASON FOR LEAVING ________________________________________________________________________________________
DESCRIBE YOUR DUTIES AND WORK EXPERIENCE: __________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
EMPLOYER ______________________________________________ TELEPHONE NUMBER ________________________________
ADDRESS ________________________________________________ DATES EMPLOYED __________________________________
JOB TITLE ______________________________________________ SUPERVISOR’S NAME ________________________________
REASON FOR LEAVING ________________________________________________________________________________________
DESCRIBE YOUR DUTIES AND WORK EXPERIENCE:__________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
REMARKS:__________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I AFFIRM THE STATEMENTS MADE ON THIS APPLICATION (INCLUDING ATTACHED PAPERS) ARE TRUE UNDER THE
PENALTIES OF PERJURY. FALSE STATEMENTS SHALL BE SUFFICIENT CAUSE FOR DISMISSAL.
DATE _______________________________ SIGNATURE OF APPLICANT_______________________________________
Rev 12/2012
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THE CITY OF BINGHAMTON IS AN EQUAL OPPORTUNITY EMPLOYER WITH A COMMITMENT
TO WORKFORCE DIVERSIFICATION.
City of Binghamton
Release and Authorization to Conduct
Criminal Conviction Background Check
In consideration of the City of Binghamton’s evaluation of my suitability for employment, I,
_______________________, do hereby authorize and agree that the City of Binghamton may
perform a full criminal conviction background check in order to verify the information I have
provided in this regard on the City’s employment or exam application. I understand and agree that
the City may obtain any criminal court documents and/or police records which may be relevant to any
and all of my criminal convictions, whether or not I have listed such criminal convictions on the
City’s employment or exam application. I further understand that my failure to make a full disclosure
of any criminal convictions as requested on the City’s employment or exam application or my
intentionally making false statement(s) regarding any criminal convictions(s) may subject me to
immediate dismissal at any time in the future.
I agree not to assert any claims or causes of action of any kind against the City of
Binghamton, its officials, its agents, and/or its employees as a result of this criminal conviction
background check. I further release and forever discharge the City of Binghamton, its officials, its
agents, and its employees from any and all claims, demands, damages, actions, causes of action or
suits or any kind of nature whatsoever arising from the City’s investigation of my criminal conviction
background. I acknowledge that the City of Binghamton has made no representations of any kind as
to whether employment will be offered at the conclusion of this criminal conviction background
check.
_____________________________ ________________
Signature of Applicant Date
FAILURE TO COMPLETE AND SIGN THIS FORM WILL DISQUALIFY YOU FROM ANY
CONSIDERATION FOR EMPLOYMENT WITH THE CITY OF BINGHAMTON.
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Mu City Hall, Government Plaza 38 Hawley Street, (City of Binghamton)

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Completed 2 August 2020

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