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VILLAGE OF CALEDONIA A pp li ca o (Village of Caledonia)

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VILLAGE OF CALEDONIA
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Employment
A
pp
li
ca
t
i
o
n
Yo
u
m
us
t
c
omp
l
ete
t
h
e
e
n
t
i
r
e
application by including thorough, complete and accurate information.
D
a
t
e
:
PERSONAL
I
N
F
OR
M
A
T
I
ON
NAME
(
L
AS
T
,
FIRST,
M
I
DD
L
E
)
TELEPHONE
NO.
PRESENT
ADDRESS
CITY
STATE
ZIP CODE
ARE YOU UNDER 18? ARE YOU LEGALLY
AUTHORIZED
TO WORK IN THE U.S.?
YES
NO
YES
NO
REFERRAL
SOURCE:
Newspaper Ad
Friend
Walk-In
Employee
Other
(
P
L
E
AS
E
I
D
E
N
TIF
Y
)
EMPLOYMENT D
ES
I
R
E
D
Position Desired
Full-time
Part-time
Summer
Shift
(
P
l
ea
s
e
c
ir
c
l
e
)
: 1 2 3 Open
Have you been employed previously by the Village of Caledonia?
Yes
No If so, indicate location and
d
a
t
e
s
D
a
t
e
a
v
a
il
a
b
l
e
?
W
a
g
e
/
S
a
l
a
ry r
e
q
uir
e
d
$
EMPLOYMENT H
I
S
TORY
(Account for all time last 10
y
ear
s
)
1
PRESENT
OR LAST EMPLOYER
DATES
EMPLOYED
YOUR
POSITION
AND
DESCRIPTION
OF DUTIES
FROM
MO / YR
TO
MO / YR
ADDRESS ZIP CODE
CITY PHONE
REASON
FOR LEAVING
IMMEDIATE
SUPERVISOR
F
ULL
-
TI
M
E
PA
RT
-
TI
M
E
STARTING
SALARY
FINAL SALARY
M
a
y
w
e
c
on
t
a
c
t
your
p
r
e
s
e
n
t
e
m
p
loy
e
r no
w
?
Y
e
s
No
I
f
“
no,
”
w
h
e
n m
a
y
w
e
c
on
t
a
c
t
?
2
EMPLOYER
DATES
EMPLOYED
YOUR
POSITION
AND
DESCRIPTION
OF DUTIES
FROM
MO / YR
TO
MO / YR
ADDRESS ZIP CODE
CITY PHONE
REASON
FOR LEAVING
IMMEDIATE
SUPERVISOR
F
ULL
-
TI
M
E
PA
RT
-
TI
M
E
STARTING
SALARY
FINAL SALARY
3
EMPLOYER
DATES
EMPLOYED
YOUR
POSITION
AND
DESCRIPTION
OF DUTIES
FROM
MO / YR
TO
MO / YR
ADDRESS ZIP CODE
CITY PHONE
REASON
FOR LEAVING
IMMEDIATE
SUPERVISOR
F
ULL
-
TI
M
E
PA
RT
-
TI
M
E
STARTING
SALARY
FINAL SALARY
4
EMPLOYER
DATES
EMPLOYED
YOUR
POSITION
AND
DESCRIPTION
OF DUTIES
FROM
MO / YR
TO
MO / YR
ADDRESS ZIP CODE
CITY PHONE
REASON
FOR LEAVING
IMMEDIATE
SUPERVISOR
F
ULL
-
TI
M
E
PA
RT
-
TI
M
E
STARTING
SALARY
FINAL SALARY
5
EMPLOYER
DATES
EMPLOYED
YOUR
POSITION
AND
DESCRIPTION
OF DUTIES
FROM
MO / YR
TO
MO / YR
ADDRESS ZIP CODE
CITY PHONE
REASON
FOR LEAVING
IMMEDIATE
SUPERVISOR
F
ULL
-
TI
M
E
PA
RT
-
TI
M
E
STARTING
SALARY
FINAL SALARY
REV. 11/17
VILLAGE OF CALEDONIA
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
E
DUC
A
T
I
ON
NAMES AND
ADDRESSES
OF SCHOOLS ATTENDED
HIGH SCHOOL
NO. OF YEARS
ATTENDED
MAJOR
FIELD
OF STUDY
G
R
AD
E
PO
I
N
T
A
VER
AG
E
GRADUATE?
YES NO
COLLEGE
OR
UNIVERSITY
(
L
I
S
T
)
TECHNICAL
SCHOOL OR OTHER
OTHER EDUCATION, SPECIAL TRAINING
OR
COURSES
COMPLETED
PROFESSIONAL HONORS AND PROFESSIONAL ASSOCIATIONS
LIST ANY PROFESSIONAL HONORS YOU RECEIVED
AND
PROFESSIONAL ORGANIZATIONS IN WHICH YOU ARE ACTIVE
(
e
x
c
lu
d
e
any which indicate age, sex, race, religion, national origin, or other protected status, unless related to the job
)
.
MILITARY
SE
R
V
I
C
E
U.S. MILITARY
S
ERVI
C
E
YES N
O
YEARS
OF SERVICE
HIGHEST
RANK
DESCRIPTION
OF DUTIES
BRANCH OF SERVICE
ADDITIONAL
I
N
F
OR
M
A
T
I
ON
Other qualifications, certifications, licenses, skills and abilities that may help you qualify for this position
R
EFE
R
E
NC
ES
Give The Names Of Three Persons Not Related To You, Whom You Have Known At Least One Y
e
a
r And Who Thoroughly Understand Your Professional Abilities
NAME
PHONE
RELATIONSHIP
YEARS
KNOWN
1.
2.
3.
TO BE READ AND SIGNED BY APPLICANT
Please Read Carefully Before Signing This Form
All information contained in this application is true and correct to the best of my knowledge and belief. I understand the importance of this requirement and the Village’s
reliance on my assertions. I understand and agree that any misrepresentation, false assertion, or omission of any kind concerning information provided on this Application or
information provided by me during the hiring process shall be a sufficient basis for denial of employment or immediate termination if I am hired. I further understand and agree
that my failure to provide requested information in a timely manner or failure to promptly correct inaccurate information shall be sufficient basis for denial of employment or
immediate termination if I am hired.
I un
derstand the Village of Caledonia may investigate my background, including my responses on this application, and contact any of my former employers or any individuals
familiar with me or my professional background for the purpose of verifying information I have provided or for the purpose of obtaining job-related information, whether
favorable or unfavorable, about me. I understand the Village may conduct a drug screening and other non-medical examinations. I understand that upon receiving a
conditional job offer, a physical examination and other medical examination may be required.
I re
cognize this application is not and should not be considered a contract of employment. I understand that employment at the Village of Caledonia is on an at-will basis and
that my employment may be terminated for no reason or any lawful reason, and without notice, at any time, at my option or the Village of Caledonia’s option. I further
understand that no Village employee or officeholder has the authority to enter into a contract regarding duration or terms and conditions of employment other than the Village
Board at a duly noticed meeting, and then only by means of a signed, written document intended to be an employment contract.
By s
igning below, I agree that I have read and understand the above-referenced provisions.
Da
t
e
Signature _________________________________________________________
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VILLAGE OF CALEDONIA A pp li ca o (Village of Caledonia)

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Completed 13 August 2020

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