Position(s) Applied For Date Of Application
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Last Name
First Name M.I.
Address:
Phone Number: Day Evening
Social Security Number (Voluntary)

Best time to contact you at home is:  AM   PM  
If you are under 18 years of age, can you provide required proof
of your eligibility to work? 		 Yes   No  
Have you ever filed an application 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 friends or relatives, other than spouse, work here?  Yes   No  

Are you currently employed?  Yes   No  
May we contact your present employer?  Yes   No  
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?  Yes   No  
(Proof of citizenship or immigration status will be required upon employment)
Date available for work:
What is your desired salary range?
Are you available to work:
Full-Time - Indicated Shift(s) Available: Shift 1 Shift 2 Shift 3
Part-Time - Indicate Availability: Mornings Afternoons Evenings
Temporary - Dates Available: -
Are you currently on “lay-off” status & subject to recall?  Yes   No  
Can you travel if a job requires it?  Yes   No  
Have you been convicted of a felony within the last five years?  Yes   No  
(A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.)

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EDUCATION

Elementary School

Name & Address Of School
Course of Study
Number of Years Completed
Diploma Degree

High School

Name & Address Of School
Course of Study
Number of Years Completed
Diploma Degree

Undergraduate College

Name & Address Of School
Course of Study
Number of Years Completed
Diploma Degree

Graduate Professional

Name & Address Of School
Course of Study
Number of Years Completed
Diploma Degree

Other (Specify)

Name & Address Of School
Course of Study
Number of Years Completed
Diploma Degree

Describe any specialized training, apprenticeship, skills and extra-curricular activities:
Describe any job-related training received in the United States Military:

EMPLOYMENT EXPERIENCE

Employer
Address
Telephone No.
Job Title/Supervisor
Reason For Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Work Performed

Employer
Address
Telephone No.
Job Title/Supervisor
Reason For Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Work Performed

Employer
Address
Telephone No.
Job Title/Supervisor
Reason For Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Work Performed

Employer
Address
Telephone No.
Job Title/Supervisor
Reason For Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Work Performed

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:

ADDITIONAL INFORMATION

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills (check skills/equipment operated)

 Terminal    Spreadsheet    PC/MAC    Word Processing  
 Typewriter (WPM: )    Shorthand (WPM: )

Production/Mobile Machinery (list)

Other (list)
State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?  Yes   No  

References

1. Name Phone
(###) ### - ####
2. Name Phone
(###) ### - ####
3. Name Phone
(###) ### - ####
4. Name Phone
(###) ### - ####
5. Name Phone
(###) ### - ####

ALCOHOL & DRUG TESTING POLICY

Due to health and safety risks of alcohol & drug abuse, applicants selected for employment, by the City of Belton, in Law Enforcement, Department of Transportation (DOT) or safety-sensitive positions will be required to undergo a drug test. A positive test result, indicating illegal drug use, will disqualify you from consideration for employment. A negative test result, indicating being free of drugs, will not guarantee employment. Any applicants no willing to comply with this requirement may simply excuse themselves prior to completing the attached application forms. All DOT regulated positions are subject to on-going testing during employment with the City of Belton.
 
 
I understand and agree to the above testing requirements.
 
Signature of Applicant (Type Name)
 
Date
 
Drivers License #

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.




Signature of Applicant (Type Name)

Date