Typeset from the PDF of the official document — headings, motions and recorded votes are detected automatically, so spacing may differ from the original. The official copy governs.
Employment Application Please read these instructions carefully.
• To be considered an applicant to the Town of Clay, you must complete all parts of this application and sign the Applicant Statement. Incomplete applications will not be considered. Please use additional sheets of paper if necessary to provide all the requested information. You may attach a resume; however, this application must still be completed.
• If you need help filling out this application, or for any phase of the employment process, please let us know, and every reasonable effort will be made to accommodate your needs.
All qualified applicants will receive consideration without regard to race, color, creed, religion, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other basis upon which discrimination is prohibited by municipal, state, or federal law.
General Information Last Name First Name Middle Name Primary Phone Work Phone Other Phone Email Current Address - Street/Apt # City State Zip Code If hired can you prove that you are eligible for employment in the Are you over the age of 18 years? (If no you may be required to United States? provide authorization to work.) No Yes No Yes Is there any information we would need about your name for us to be able to check your work record? If yes, explain: No Yes Position Information Position desired: Have you been previously employed by the Town of Clay? No Yes If yes, when? What position?
Please check all that you are available for: Have you ever applied for employment with us? Full time Part time Temporary No Yes If yes, month and year: Overtime Evenings Weekends Holidays When would you be able to start work? Minimum acceptable starting wage: $ ________ per hour week What days/hours are you available to work? What made you apply at the Town of Clay? Employment Ad Current Employee Former Employee Employment Agency School or College Walk-in/self Are you available to work overtime? Yes No Other: _____________ Can you travel if necessary? Yes No If referred by person, list name: _________________________ If yes, what percentage of the time? ____________ If driving is a requirement of the job for which you are applying, do you have a current, valid driver’s license? Yes No
Employment History Although a resume may be attached, you must complete this section. If you have had additional employers, not listed on this page, please attach another sheet of paper containing the same information as asked for below.
Name of Employer Location (Address, City, State, Zip) Phone Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? Yes No If no, explain:
Name of Employer Location (Address, City, State, Zip) Phone Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? Yes No If no, explain:
Name of Employer Location (Address, City, State, Zip) Phone Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? Yes No If no, explain:
Name of Employer Location (Address, City, State, Zip) Phone Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? Yes No If no, explain:
Name of Employer Location (Address, City, State, Zip) Phone Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? Yes No If no, explain:
Other History Have you had any employment that is not listed on the previous Please describe any military service you had, including dates: page? No Yes If yes, please explain.
Education School Name & Location Degree Earned Course of Study High School None Diploma GED Business/Trade/Tech None List:
nical College None Associate Bachelor Graduate Studies None Master Other (explain) Training Please describe any training you have had that would be relevant to the job for which you are applying:
Special Skills Please list any skills or accreditations you posses that are not reflected elsewhere in this application (special license and/or business certification) Additional Information Please tell us anything else that may help us with our hiring decision:
References Give name, address & telephone of three professional references that are not related to you.
Name Address Phone 1.
2.
3.
Applicant Statement I certify that the answers given herein are true and complete to the best of my knowledge. I realize that any misrepresentation in the information submitted or any intentional withholding of essential information called for in this form may result in my immediate dismissal.
I understand that the filling of this application with the Town of Clay is a preliminary step to employment. It does not obligate the Town to offer employment, or the applicant to accept employment. An offer of employment, if made, is contingent upon receiving satisfactory background and reference checks as authorized by this statement and any other attachments. I understand that if I receive a contingent offer of employment and I accept the position, I may be required to complete additional information necessary for record keeping requirements. I agree to abide by all Town of Clay policies and procedures as outlined within the Town’s policies, memos, handbooks, and other documents.
I authorize the Town of Clay to check all references from current and previous employers and other references that may be relevant to my employment or my ability to perform the job for which I have applied. I authorize the Town of Clay and/or its agents to verify any of the information furnished in this application and other background information deemed appropriate by the Town. By signing this application, I authorize all persons, schools, and companies and law enforcement authorities and agencies to release any information concerning my background that may be relevant to evaluation of this employment application and I hereby release any such persons, schools, companies, and law enforcement authorities and agencies from any liability for damages whatsoever for issuing this information to the Town or its agents. The Town will keep all such information confidential except where such information is required to be released by law, order of a court or other authority, or by any contractual agreement. I understand and hereby acknowledge that any employment relationship with the Town is at will, which means that, if I am hired, my employment with the Town is not for a fixed period of time and that I may resign at any time and the Town of Clay may terminate my employment and compensation at any time. I further agree that this at will employment relationship may not be changed by any written document or by conduct of any Town employee or official.
Applicant Signature Date Thank you for completing an application for employment with the Town of Clay; we appreciate your interest in working with us!