HUMAN RESOURCES DEPARTMENT
P. O. Box 100
104 NORTH RIVERSIDE DRIVE, EDGEWATER, FL 32132
(386) 424-2400 Ext. 1703 FAX (386) 424-2474
APPLICATION FOR EMPLOYMENT WITH THE CITY OF EDGEWATER
The City of Edgewater is an Equal Opportunity Employer and will not discriminate
against any person because of race, color, religion, creed, gender, age, national origin,
disability, Veteran or marital status, or other legally protected status.
PLEASE PRINT
Position(s) Applied for: Date of Application
How did you learn about us? (Please circle one)
Friend Walk-In
City Web Site
Employment
Agency
Relative Other
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number (s):
Have you ever filed an ap
plication with us before? ______Yes _______No If yes, give date ____________
Have you ever been employed with us before? ______Yes _______No If yes, give date ___________
Do any of your relatives work here? ______Yes _______No If yes, list name and
your relationship____________________________________________________________
May we contact your present employer? _______Yes _______No
On what date would you be available for work? _________________________
Are you available to work: Full Time Part Time Shift Work Temporary
Are you currently on “lay-off” status and subject to recall? _______ Yes _______No
Can you travel if a job requires it? Yes No
Are you a United States citizen _______Yes _______No
If not, do you possess an Alien Registration Card? _______Yes _______No
If yes, give Al
ien Registration #___________
Have you been convicted of a felony? Yes No
Conviction will not necessarily disqualify an applicant from employment.
If yes, please explain________________________________________________________________________
EDUCATION/ SPECIALIZED TRAINING
Years Diploma
Name and Address
of School
Completed Degree
Elementary
School
High
School
Graduate
Professional
Other (Specify)
_____________________________________________________________________________________________
Describe any specialized education, training, apprenticeship, and/or skills.
List professional, trade, business or civic activities and offices held.
You may exclude membership, which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.
Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
Check Skills/Equipment O
perated
___ Copier ___ Fax ___ Typewriter
___ Calculator ___ Multi-line Telephone ___ CRT
___ PC/ Software applications (list): ________________ Other (list):_________________________
________________________________________ ______________________________
Driver’s License # ________________________________ Expiration Date: ____________________
CDL/ Type: _________ Operators __________
MILITARY SERVICE RECORD
It is City policy to give preference to eligible veterans and spouses of veterans in accordance with Chapter 295,
Florida Statutes.
Were you in the U.S. Armed Forces? ______Yes _______No If yes, list any job
related training
_______________________________________________________________________
______________________________________________________________________________
Are you claiming Veteran’s Preference as a:
______ Disabled veteran
______ Spouse of totally disabled veteran or who is MIA
______ Veteran of any war
______ Unremarried widow or widower of a veteran who died of a service-connected
disability
Have you claimed Veteran’s Preference since October 1, 1987? ______Yes _______No
The applicant claiming preference is responsible for providing the required documentation when
submitting their application.
EMPLOYMENT EXPERIENCE
START W
ITH YOUR PRESENT OR LAST JOB.
Employer Dates Employed
Work Performed
From To
Address
Employer Dates Employed
Work Performed
From To
Address
Employer Dates Employed
From To
Address
Employer Dates Employed
From To
Address
REFERENCES
1. ( )
Name Phone
Address
2. ( )
Name Phone
Address
APPLICANT’S CERTIFICATION AND AGREEMENT
I understand that any false answers or statements made by me on this application or any supplement thereto, or any false statement
made to any representative of the City of Edgewater during the interview process, will be sufficient grounds for immediate discharge, no
matter when discovered.
I understand and agree that if I am hired by the City of Edgewater, my employment is for no definite period and may be terminated at
any time without previous notice or cause. I understand that no supervisor or other representative of the City of Edgewater has the
authority to enter into any agreement for employment for any specified period of time, except by written authorization by the City
Manager.
I understand and agree that the City of Edgewater will make a thorough investigation of my character, reputation and past employment.
I authorize the giving and receiving of any such information requested by the City of Edgewater and hereby release all former employers
and their agents of any liability for any information they may give to the City of Edgewater. I hereby waive any rights or claims I may
have, whether presently fully developed or not, against the City of Edgewater or its agents or employees arising out of, or resulting from
the release, authorized or unauthorized, of the information received pursuant to or in connection with the City of Edgewater’s handling,
processing, or investigation of my application with the City of Edgewater.
I agree to a physical examination if requested, including testing for the use of illegal drugs, controlled substances or alcohol, prior to
hiring, and at any time during my employment based upon reasonable suspicion and/or Federal and State regulations.
I hereby acknowledge that my employment with the City of Edgewater will begin with a designated probationary period.
_____________________________________________________ _______________________________
Applicant’s Signature Date
Work Performed
Work Performed
click to sign
signature
click to edit
ADDITIONAL COMMENTS
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