APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

We are a smoke-free establishment per A.R.S. §36-601.01. The telephone number for making complaints is 1-877-429-6676 or online at www.smokefreearizona.com We are an equal opportunity employer.

(PLEASE PRINT)

Position(s) Applied For:

Date of Application:

How Did You Learn About Us?

____ Advertisement ____ Friend ____ Walk-In ____ Web Site

____ Employment Agency ____ Relative ____ Other ______________________________________________________________

Last Name: First Name: Middle Name:

Address: PO Box & Street Address City: State: Zip:

Telephone Number(s)

Social Security Number:

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

Have you ever been employed with us before? __ 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?

Proof of citizenship or immigration status will be required upon employment. __ Yes __ No

On what date would you be available for work? ___________________

Are you available to work: _____ Full Time _____ Part Time _____ Shift Work _____ Temporary

Are you currently on “lay-off” status and subject to recall? __ Yes __ No

Can you travel if a job requires it? __ Yes __ No

Have you ever been convicted of a felony or a misdemeanor crime of moral turpitude? __ Yes __ No

Conviction will not necessarily disqualify an applicant from employment.

If Yes, please explain _______________________________________________________________________________

_________________________________________________________________________________________________

EDUCATION

	Name & Address of School	Course of Study	Years Completed	Diploma/Degree
Elementary School
High School
Undergraduate College
Graduate Professional
Other (Specify)

Indicate any foreign languages you can speak, read and/or write
	Fluent	Good	Fair
SPEAK
READ
WRITE

Describe any specialized training, apprenticeship, skills and extra-curricular activities:

_________________________________________________________________________________________________

Describe any job-related training received in the United States military:

__________________________________________________________________________________________

_________________________________________________________________________________________________

EMPLOYMENT EXPERIENCE

Employer

1. _________________________________________

Address

__________________________________________

Telephone Number(s)

__________________________________________

Job Title Supervisor

__________________________________________

Reason for Leaving

Dates Employed:

From

Hourly Rate/Salary:

Starting

Final

Work Performed

Employer

2. _________________________________________

Address

__________________________________________

Telephone Number(s)

__________________________________________

Job Title Supervisor

__________________________________________

Reason for Leaving

Dates Employed:

From

Hourly Rate/Salary:

Starting

Final

Work Performed

Employer

3. _________________________________________

Address

__________________________________________

Telephone Number(s)

__________________________________________

Job Title Supervisor

__________________________________________

Reason for Leaving

Dates Employed:

From

Hourly Rate/Salary:

Starting

Final

Work Performed

Employer

4. _________________________________________

Address

__________________________________________

Telephone Number(s)

__________________________________________

Job Title Supervisor

__________________________________________

Reason for Leaving

Dates Employed:

From

Hourly Rate/Salary:

Starting

Final

Work Performed

If you need additional space, please continue on a separate sheet of paper.

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

____ PC ____ Fax Production/Mobile

Machinery (list): Other (list):

____ Calculator ____ Windows O.S.

____ Typewriter ____ MS Office _______________ _______________

____ Word Perfect ____ Digital Camera _______________ _______________

_______________ _______________

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

_________________________________________________________________________________________________

References:

1. ______________________________________________________________________________________________

(NAME) (Phone #)

______________________________________________________________________________________________

(Address)

2. ______________________________________________________________________________________________

(NAME) (Phone #)

______________________________________________________________________________________________

(Address)

3. ______________________________________________________________________________________________

(NAME) (Phone #)

______________________________________________________________________________________________

(Address)

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

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

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

I understand that the Town of Quartzsite is a smoke-free establishment per A.R.S. §36-601.01. The telephone number for making complaints is 1-877-429-6676 or online at www.smokefreearizona.com.

We are an equal opportunity employer

_____________________________________________ ______________________

Signature of Applicant Date

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview ____ Yes ____ No

Remarks ______________________________________________________________________________________

______________________________________________________________________________________

Employed ____ Yes ____ No Date of Employment_____________________________________

Job Title _____________________________ Rate of Pay ________________________ Dept._________________

By___________________________________________________________________________

Name & Title Date

NOTES:__________________________________________________________________________________________

_________________________________________________________________________________________________

EDUCATION

Indicate any foreign languages you can speak, read and/or write