City
Offices
44
S Main
Eureka
Springs, AR 72632
479-253-9703
NAME:___________________________________________________________DATE:______________
(Last) (First) (Middle)
MAILING
ADDRESS:___________________________________________________________________
CURRENT
TELEPHONE NO. OR NO. WHERE YOU COULD BE REACHED:____________________
POSITION
YOU ARE APPLYING FOR:____________________________________________________
If
hired, can you produce evidence of U.S. Citizenship or legal work status within
three (3)days?_________
PREVIOUS
EMPLOYMENT: List employers, including military services, for at least the past
five (5) years.
Begin with the most recent and work back.
Attach additional sheets or resume to provide sufficient qualifying experience
data.
From:___________________________________ To:________________________________________
Job
Title:________________________________ Annual
Salary:_______________________________
Company
Name:__________________________ City,
State:__________________________________
Name
of Direct
Supervisor:________________________________________________________________
Reason
for
Leaving:______________________________________________________________________
Description
of Work:_________________________________________________________________________________
______________________________________________________________________________________
From:___________________________________ To:________________________________________
Job
Title:________________________________ Annual
Salary:_______________________________
Company
Name:__________________________ City,
State:__________________________________
Name
of Direct Supervisor:________________________________________________________________
Reason
for
Leaving:______________________________________________________________________
Description
of
Work:_________________________________________________________________________________
______________________________________________________________________________________
From:___________________________________ To:________________________________________
Job
Title:________________________________ Annual
Salary:_______________________________
Company
Name:__________________________ City,
State:__________________________________
Name
of Direct
Supervisor:________________________________________________________________
Reason
for
Leaving:______________________________________________________________________
Description
of Work:_________________________________________________________________________________
_____________________________________________________________________________________.
EDUCATION: Did you graduate from high school? Yes________ No:_________
Name and address of high
school___________________________________________________________
Last grade completed and date of completion
or graduation______________________________________
College
University Date
Trade,
Business, Dates Majors Left
Correspondence of Areas of Semester Degrees or
School Attendance Study Hours Granted Graduated
__________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Can
you perform the duties of the job for which you are applying for? Yes:_________ No:_________
If
no, please
explain?___________________________________________________________________
List
all licenses you hold: (Driver’s, electrician, plumbers, CDL, etc.)
Type:___________________________Number______________________Expiration
Date:___________
Type:___________________________Number______________________Expiration
Date:___________
Type:___________________________Number______________________Expiration
Date:___________
Specify
equipment or office machines you
operate:____________________________________________
____________________________________________________________________________________.
Are
you related to any member of the elected city government or any person now in
the employ of the city in any department.
Yes:__________
No:______________
If
yes, give person’s name, where employed
and his/her relationship to you:_________________________
_____________________________________________________________________________________.
Person
to be notified in case of emergency:
Name:____________________________________________.
Address:__________________________________________Phone:______________________________
Reference:
Give the names, addresses, and phone number of three (3) persons, other than
relatives, who have knowledge of your character, experience or ability:
NAME ADDRESS PHONE OCCUPTION
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please
indicate any additional work experience and training you have had which in your
opinion would qualify you for the position you
seek:________________________________________________________
______________________________________________________________________________________
I
understand that this application is not intended to create any contractual or
other legal rights. It does not alter at-will employment status nor does it
create an employment contract for any specific period of time.
I
certify that I have made no willful misrepresentations in this application nor
have I withheld information in my statement and answer to questions. I am aware
that information given by me in my application will be investigated, with my
full permission, and that any misrepresentations may cause my application to be
rejected or my employment terminated.
I
authorized any former employer to release to the city or its authorized
representatives any and all employment records and other information it may
have about my employment. I understand that the information will be used for
the purpose of evaluating my application for employment with the city. A
photocopy of this authorization shall be as valid as the original.
I
understand that this appointment will be at the discretion of the department
head concerned, subject to the approval of the City Council, and that this
application is the property of the city and will become a part of my file if I
am accepted for employment.
______________________________________________________________________________________
Signature
of Applicant