Application for Employment TOWN OF SOUTHBURY, CT Page 1 of 5
TOWN OF SOUTHBURY
APPLICATION FOR EMPLOYMENT
Pre-Employment Questionnaire | An Equal Opportunity Employer
PERSONAL INFORMATION
NAME (Last, First, Middle)
PRESENT ADDRESS (Street, City, State, Zip)
PERMANENT ADDRESS (Street, City, State, Zip)
PHONE EMAIL ARE YOU 18 YEARS OR OLDER? Yes No
EMPLOYMENT
Position Desired
Date you can start Salary desired
Are you employed now? Yes No If yes, may we inquire of your present employer? Yes No
Are you legally authorized to work in the United States? Yes No
Referred by: Employment Agency Newspaper Advertising Website Email Friend Walk-In
State Employment Office Other-Please Specify
EDUCATION
Name of School and Town
Number of
years attended
Did you
graduate?
Major
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR
OTHER SCHOOL
GENERAL
Subjects of special study or research work
Special training
Special skills
Computer
related experience
Application for Employment TOWN OF SOUTHBURY, CT Page 2 of 5
FORMER EMPLOYERS
List below your past employers, starting with the most recent. Continue on a separate sheet if necessary.
Name of present or last employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Name of previous employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Name of previous employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Application for Employment TOWN OF SOUTHBURY, CT Page 3 of 5
Name of previous employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Name of previous employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Name of previous employer
Address
Starting date Leaving date Job title
May we contact your supervisor? Yes No
Name of supervisor Title Phone
Description
of work
Reason for leaving
Application for Employment TOWN OF SOUTHBURY, CT Page 4 of 5
REFERENCES
Please provide name, address, email address and telephone number of three references that are not related to you:
Name
Address
Email address
Phone number
1.
2.
3.
SERVICE RECORD
Branch of service
Rank
Discharge date
Application for Employment TOWN OF SOUTHBURY, CT Page 5 of 5
APPLICANT’S STATEMENT
TO ALL APPLICANTS: PLEASE READ THIS SECTION CAREFULLY AND SIGNIFY YOUR UNDERSTANDING BY SIGNING YOUR
NAME IN THE SPACE PROVIDED.
I certify that all of the statements made by me on this application for employment are true, correct, and complete to
the best of my knowledge. I understand that any falsification or material omission of fact on this application shall lead
to refusal of employment or dismissal from employment.
I authorize the Town of Southbury (the “Town”) to check the references provided, and further authorize the
investigation of all matters contained in this application to verify its accuracy, including past employment.
I understand that, as part of the application process, the Town conducts thorough background checks (which may
include a check of my criminal history) on prospective employees. I agree that, if contacted with respect to such
background check, that I will fully cooperate and provide any information requested. understand that, as a condition
of my consideration for employment with the Town, or as a condition of my continued employment with the Town,
the Town may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar
characteristics, employment and education verifications, social security verification, criminal and civil history,
personal interviews, DMV records, any other public records and any other information bearing on my credit standing,
credit capacity, character, general reputation, personal characteristics and trustworthiness.
I hereby authorize and consent to the Town’s procurement of such a report. I understand that, pursuant to the
federal Fair Credit Reporting Act, the Town will provide me with a copy of any such report if the information
contained in such report is, in any way, to be used in making a decision regarding my fitness for employment with the
Town. I further understand that such report will be made available to me prior to any such decision being made, along
with the name and address of the reporting agency that produced the report.
As a condition of employment, I understand that information relative to the status of any driving duties, particularly
insurability of an employee who drives as part of his/her job, is an important job function. In the event that I am
called upon to drive as part of my job functions with the Town then as a condition of my employment, I hereby
authorize my employer and its insurance agent to ask for and receive information relative to the status of my motor
vehicle operator’s license and motor vehicle history in every State in which I have held a motor vehicle operator’s
license.
This authorization is valid from the date of my signature below throughout the term of my employment in which
driving a Town motor vehicle is an essential job function. I understand that if at any time (now or in the future) the
Town cannot insure me due to my motor vehicle operator history, my employment may be terminated.
APPLICANT’S SIGNATURE DATE
NOTE: A typed name will substitute for a handwritten signature.
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