Employment Application

Employment Application

City of Pearl
The City of Pearl is AN EQUAL OPPORTUNITY EMPLOYER does not discriminate on the basis of race, color, religion, sex, age, sexual orientation, gender identity, national origin, veteran or disability status.
Name:
Date of Application:

Month Day Year
Date
Social Security #:
Position Applying for - First Choice:
Position Applying for - Second Choice:
Address
Street Address First Line - Press Enter - City, State & Zip Second Line
Phone Number:
Email:
example@example.com
PERSONAL DATA
Are you 18 years of age or older?

Yes No
Do you have a valid Driver’s License?

Yes No
If yes, from which state?
Driver’s License #
Do you have any relatives who are employees of the City of Pearl?

Yes No
NAME, RELATIONSHIP, DEPARTMENT
Have you ever been arrested, detained or charged with any crime, including traffictickets but not parking tickets?

Yes No
If yes, enter the following information below - Date, Charge, Disposition, Details - for each offense:
EDUCATION
Graduated or Equivalent (GED)::

Yes No
High School Name & Address:
Enter Name on First Line - press Enter - Enter Address on Second Line
Year Diploma Awarded:

College/Universities:

	Name/location of college or universities	Dates attended from /to	QTR.HR SEM.HR	-	Major	Minor	GPA	Date degree obtained

List any school/college honors:
List any additional school/college honors:
List any professional, trade, business, or civic activities and offices held. (You may exclude those that indicate race, religion, sex, or national origin:
Professional, trade, business or civic activities continued - Line 2:
Special skills or training - Line 1:
Special skills or training - Line 2:
Are you a veteran of the U.S. military service?

Yes No
If yes, select which branch

Army Air Force Navy Marines Coast Guard
STARTING DATE

Month Day Year
ENDING DATE

Month Day Year
Highest Rank Achieved:
Type of Discharge & Date:
Enter Type of Discharge & MM/DD/YYYY
Duties or Training:
Are you now a member of the Reserves?

Yes No
What branch?
Select One:

Active Inactive
Area of training:
PREVIOUS RESIDENCES PREVIOUS RESIDENCES
List chronologically all your previous residences for the past five (5) years. If you need additional space, please attach another sheet.

Dates

	From	To	Street Address	City	County	State	Zip

EMPLOYMENT HISTORY

List in order, beginning with your current or last employer, and describe duties performed.
NAME OF CURRENT OR LAST EMPLOYER
EMPLOYER PHONE NUMBER
JOB TITLE
ENDING SALARY:
ENTER EMPLOYER ADDRESS BELOW:

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
STARTING DATE

Month Day Year
Date
ENDING DATE

Month Day Year
Date
NAME & TITLE OF IMMEDIATE SUPERVISOR
SELECT ONE

Full Time Part Time
Reason for leaving:
Statement of duties - LINE 1:
Statement of duties - LINE 2:
NAME OF CURRENT OR LAST EMPLOYER
EMPLOYER PHONE NUMBER
JOB TITLE
ENDING SALARY:
ENTER EMPLOYER ADDRESS BELOW:

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
STARTING DATE

Month Day Year
Date
ENDING DATE

Month Day Year
Date
NAME & TITLE OF IMMEDIATE SUPERVISOR
SELECT ONE

Full Time Part Time
Reason for leaving:
Statement of duties - LINE 1:
Statement of duties - LINE 2:
NAME OF CURRENT OR LAST EMPLOYER
EMPLOYER PHONE NUMBER
JOB TITLE
ENDING SALARY:
ENTER EMPLOYER ADDRESS BELOW:

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
STARTING DATE

Month Day Year
Date
ENDING DATE

Month Day Year
Date
NAME & TITLE OF IMMEDIATE SUPERVISOR
SELECT ONE

Full Time Part Time
Reason for leaving:
Statement of duties - LINE 1:
Statement of duties - LINE 2:
NAME OF CURRENT OR LAST EMPLOYER
EMPLOYER PHONE NUMBER
JOB TITLE
ENDING SALARY:
ENTER EMPLOYER ADDRESS BELOW:

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
STARTING DATE

Month Day Year
Date
ENDING DATE

Month Day Year
Date
NAME & TITLE OF IMMEDIATE SUPERVISOR
SELECT ONE

Full Time Part Time
Reason for leaving:
Statement of duties - LINE 1:
Statement of duties - LINE 2:
PERSONAL REFERENCES

Please exclude any former employers or relatives.
NAME
PHONE
OCCUPATION
Address

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
RELATIONSHIP
NAME
PHONE
OCCUPATION
Address

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
RELATIONSHIP
NAME
PHONE
OCCUPATION
Address

STREET ADDRESS

Street Address Line 2

City STATE

ZIP
RELATIONSHIP
CERTIFICATION
The City of Pearl is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, sexual orientation, gender identity, national origin, veteran or disability status. I certify that all information provided on this application is true, complete, and correct to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment, or in the event of employment, grounds for discharge. I also understand that this application will be kept on file for a period of one (1) year from the date it is received and it is my responsibility to notify Human Resources if any information changes during that time. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the City of Pearl. The position for which I may be selected shall be evaluated for approximately one (1) year during which period, the position may be abolished or my employment may be terminated at the sole discretion of the Mayor and Board of Aldermen. Notwithstanding the preceding sentence, the term of employment of all employees shall be in accord with all applicable laws, rules, and regulations. For and in consideration of the acceptance and processing of my application for employment, I agree to hold the City of Pearl, its agents, officers and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the City of Pearl. I understand that should information of a serious criminal nature surface as a result of a background investigation, such information may be turned over to the proper authorities. I understand that if the City of Pearl makes a conditional offer of employment, I will be required to undergo a pre-employment physical examination, which includes drug/alcohol screening. I also understand and agree that, if employed I may be requested to submit to a drug/alcohol screening on a routine or neutral selection basis at any time following thirty (30) days after the City of Pearl receives the results of such pre-employment drug/alcohol tests. I understand that after my employment commences with the City of Pearl I may be required to submit to drug/alcohol screening if there is a reasonable suspicion that I have utilized alcohol or controlled substances in a manner prohibited by the City of Pearl’s Employee Drug and Alcohol Testing Policy. I hereby consent to having the results of all drug and/or alcohol screening/testing disclosed to the City of Pearl. I also understand that any refusal to consent to such screening/testing is justification for refusal of employment, or in the event of employment, grounds for discharge

Clear
DATE

Month Day Year
Date
AN EQUAL OPPORTUNITY EMPLOYER does not discriminate on the basis of race, color, religion, sex, age, sexual orientation, gender identity, national origin, veteran or disability status.
AUTHORIZATION FOR RELEASE OF INFORMATION
Having made application with the City of Pearl for employment, and desiring them to be informed of my past record, whether it be financial, academic, military, employment, judicial, criminal, driving record or personal reference, I the undersigned, hereby authorize the release of all such information, privileged, confidential or otherwise, to the City of Pearl and its representatives.

I hereby release all contributing parties of such information from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I understand my rights under Federal and State Law with regard to access and disclosure of records, and I waive these rights with the understanding that information furnished will be used by the City of Pearl in conjunction with employment procedures. While I acknowledge that this release shall be construed as broadly as lawfully possible, I understand that nothing in this release is intended to waive rights that cannot by law be released.

A photocopy or fax copy of this release form will be valid as an original thereof, even though said photocopy or fax copy does not contain an original writing of my signature.
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
Signature:

Clear
CURRENT ADDRESS:

CITY

Street Address Line 2

City STATE

ZIP CODE
Date of Birth:

Month Day Year
Date
Social Security #:
MONTH / DAY / YEAR
Home Telephone:
Work Telephone:
The City of Pearl is AN EQUAL OPPORTUNITY EMPLOYER does not discriminate on the basis of race, color, religion, sex, age, sexual orientation, gender identity, national origin, veteran or disability status.
Should be Empty:

Employment Application

PERSONAL DATA

EDUCATION

PREVIOUS RESIDENCES PREVIOUS RESIDENCES

EMPLOYMENT HISTORY

PERSONAL REFERENCES

CERTIFICATION

AUTHORIZATION FOR RELEASE OF INFORMATION