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TOWN OF WETHERSFIELD Human Resources Department 505 Silas (Town of Wethersfield)

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Revised 1/1/2019 1
TOWN OF WETHERSFIELD
Human Resources Department
505 Silas Deane Highway,
Wethersfield, CT 06109
APPLICATION FOR EMPLOYMENT
(Revision Effective 1/1/2019)
This application constitutes a part of the examination process. The Town cannot assume responsibility for the
confidentiality of information provided on an employment application. It must be completed in full even if a resume
or other supporting documents are attached. Please answer all questions fully and accurately. Applications may
be rejected or receive lower ratings because answers are incomplete, vague or evasive. Your statements may be
brief, but do not omit important information that may have relevance to the position.
POSITION APPLYING FOR: Date:
Name:
(Last) (First) (Middle)
Address:
(Street) (Town/City) (State) (Zip)
Primary Phone: Secondary Phone:
Email Address (REQUIRED):
Are you either a U.S. Citizen or otherwise legally eligible to work in the United States? Yes__________ No___________
Are you 18 Years or older? Yes____________ No____________
Can you perform the essential functions of the job for which you are applying with or without reasonable accommodation?
Yes____________ No___________
Do you have a valid Driver’s License? Yes_________ No_________ State______ Operator’s No.
Do you have a Commercial Driver’s License? Yes_________ No_________ Operator’s No.
Type of Employment Desired: (check all that are applicable) FULL TIME PART TIME SEASONAL TEMPORARY
EDUCATION:
Name of School
Attended
Address
Did you
Graduate?
Degree Awarded
High School/GED
College
Other
THE TOWN OF WETHERSFIELD IS AN EQUAL OPPORTUNITY EMPLOYER DEDICATED TO A POLICY OF NON
DISCRIMINATION IN EMPLOYMENT ON ANY BASIS PROHIBITED BY LAW.
Revised 1/1/2019 2
EMPLOYMENT HISTORY:
In the space provided below, give your employment history beginning with your most recent employer. You must include
both the month and year of employment history. List all positions held. Include any applicable military and voluntary
positions. If required, attach additional information.
Name of Employer: Phone:
Address:
Name & Title of Supervisor: May we contact?
Your Job Title: Employed: Full Time _____ Part Time _____
Employed From: ______________ To ____________ Duties & Responsibilities:
Reason for Leaving:
Name of Employer: Phone:
Address:
Name & Title of Supervisor: May we contact?
Your Job Title: Employed: Full Time _____ Part Time _____
Employed From: ______________ To ____________ Duties & Responsibilities:
Reason for Leaving:
Name of Employer: Phone:
Address:
Name & Title of Supervisor: May we contact?
Your Job Title: Employed: Full Time _____ Part Time _____
Employed From: ______________ To ____________ Duties & Responsibilities:
Reason for Leaving:
Name of Employer: Phone:
Address:
Name & Title of Supervisor: May we contact?
Your Job Title: Employed: Full Time _____ Part Time _____
Employed From: ______________ To ____________ Duties & Responsibilities:
Reason for Leaving:
Revised 1/1/2019 3
REFERENCES:
Give the names of at least three persons, other than relatives, who are familiar with your character, job qualifications and
work performance to provide information about you. Please provide complete address and phone number of reference.
Name
Address
Phone
SPECIALIZED TRAINING OR SKILLS:
List any specific qualifications or experience which are required for the position, or you feel may qualify you for the
position for which you are applying (include licenses, certifications, areas of research, professional memberships,
seminars and special awards).
Complete if applicable, I have the following skills:
___ Personal Computer ___ Microsoft Word ___ Microsoft Excel ___ Adobe
Other computer software used:
ADDITIONAL INFORMATION:
Occasionally, an application form makes it difficult for an individual to adequately summarize his/her complete
background. To help us better evaluate your qualifications for a Town position, use the space below to provide any
additional information to describe your full qualifications.
Revised 1/1/2019 4
Have you ever been fired or asked to resign from a job? Yes____________ No____________
If yes, please explain:
CERTIFICATION: Please read the following and sign where indicated.
1. I certify that there are no misrepresentations, omission or falsifications in the foregoing statements and answers
and that the entries made by me are true, complete and correct to the best of my knowledge and belief. I realize
that falsification of any information on this application may be grounds for rejection of this application or
termination of employment, if the falsification is discovered after employment commenced.
2. I understand that failure to follow directions and complete all sections of this application is grounds for immediate
dismissal from the recruitment process.
3. I give my consent to the Town to check with personal references, previous employers and educational institutions
concerning my past employment and personal history including driving and criminal records.
4. I release the Town, previous employers and educational institutions from any liability arising from disclosure of
information concerning my employment or personal history.
5. The acceptance of this application does not constitute an employment agreement. In the event I am employed by
the Town, I agree to comply with all of its orders, rules and regulations.
6. Proof of citizenship or employment eligibility in accordance with the Immigration and Reform and Control Act of
1986 will be required at time of appointment.
7. The Town reserves the right to conduct pre-employment drug and alcohol testing of all applicants. Applicant will
be required to pass a test for drugs and abuse/or alcohol misuse. Failure to pass such test will result in the
withdrawal of any offer of employment. Applicants for safety sensitive positions or those requiring CDL’s will
become participants in the Town's Drug and Alcohol Testing Program.
I hereby acknowledge that I have read the above statements and understand them.
Signature Date
How did you hear about this position?
_____ Town of Wethersfield Website _____ Referred by Town Employee
_____ Connecticut Employment Service _____ Rare Reminder
_____ Community or Professional Organization/Agency (please specify)_______________________________________
_____ Other internet advertisement (please specify)_______________________________________________________
_____ Other (please specify)_________________________________________________________________________
DO NOT WRITE BELOW THIS LINE – FOR HUMAN RESOURCES USE ONLY
“I certify that my complete application is truthful and accurate. I further certify that there have been no changes in the
information provided on the application from the time of its completion to my date of hire.”
Signature Please Print Name Date
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Revised 1/1/2019 5
Town of Wethersfield, Connecticut
Voluntary Affirmative Action Questionnaire
Instructions: Each applicant for employment with the Town of Wethersfield is requested to provide the following
information for affirmative action reporting purposes. It will be removed when your application is reviewed and the
information you provide will not be considered in the employment process.
1. Position Applied For:
2. Sex: Female Male
3. Age: 16 or less ________ 17 to 25________ 26 to 40________ 41 to 65________ 66 or older________
4. Ethnic Group: White__________ Black__________ Hispanic__________
American Indian or Native Alaskan__________ Asian or Pacific Islander_________
I certify that the above information is correct. Please print legibly.
Name: Date:
Signature:
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TOWN OF WETHERSFIELD Human Resources Department 505 Silas (Town of Wethersfield)

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Completed 17 July 2020

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