Application for Employment

Pre-Employment Questionnaire Equal Opportunity Employer

Full Name*
Email Address*
Present Address*
Present City, State Zipcode*
Permanent Address
Permanent City, State Zip Code
Primary Phone Number*
Secondary Phone Number
Referred By
Position Desired*
Date You Can Start*
Salary Desired
Are you employed now?
If so, may we inquire of your present employer?*
Ever applied for employment with City of Haven before?
If so, where and when?
Name and Location of High School*
Years Attended High School
Did you graduate high school?*
Subjects studied in High School
Name and Location of College Attended
Years Attended College
Did you graduate from this college?
Subjects studied in College
Name and Location of Trade / Business School Attended
Years Attended Trade / Business School
Did you graduate from Trade / Business School?
Subjects studied in Trade / Business School
Special Skills or Training
U.S. Military Service or Naval Service
Service Rank
Current Employer (1) Name and Address
Start Date
Position
Salary
Former Employer (1) Name and Address
Start Date
End Date
Position Held
Salary
Reason for Leaving
Former Employer (2) Name and Address
Start Date
End Date
Position Held
Salary
Reason for Leaving
Former Employer (3) Name and Address
Start Date
End Date
Position Held
Salary
Reason for Leaving
Do you possess a valid Driver's License?*
Issuing State?*
Driver's License Number?
Name of Reference 1 (Not related to you, whom you have known for at least one year)
Reference 1's Address
Reference 1's Phone Number
Years Known Reference 1
Name of Reference 2 (Not related to you, whom you have known for at least one year)
Reference 2's Address
Reference 2's Phone Number
Years Known Reference 2
Name of Reference 3 (Not related to you, whom you have known for at least one year)
Reference 3's Address
Reference 3's Phone Number
Years Known Reference 3
By checking this box, I acknowledge and authorize the statement written below.*
Repeat Email Address

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements and facts contained herein, including those related to my education and driver's license, and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the City of Haven from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

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