PLEASE PRINT INFORMATION CLEARLY

TOWN OF CEDAR BLUFF

Application for Employment

P.O. Box 38

Cedar Bluff, AL 35959

Phone: 256-779-6121 Fax: 256-779-6148

Name (LAST)		(FIRST, MIDDLE)			Other names under which you have attended school or been employed:
Street Address			City, State & ZIP
Social Security Number	Home Phone and/or Cell Phone			Work Phone	Date of Birth

Are you eligible to work in the United States?	q Yes q No
Are you 18 years of age or older?	q Yes q No
Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the job for which you are applying	q Yes q No	*NOTE A conviction record will not necessarily disqualify you from employment. IF “YES” PLEASE EXPLAIN NUMBER OF CONVICTIONS AND NATURE OF OFFENSE.
DO YOU HAVE A VALID DRIVERS LICENSE?	q Yes q No	DL #_________________________ EXP________________ STATE_______________________
DO YOU HAVE ANY ACCIDENTS IN THE PAST 3 YEARS?	q Yes q No	IF “YES” PLEASE EXPLAIN:
DO YOU HAVE ANY MOVING VIOLATIONS IN THE PAST 3 YEARS?	q Yes q No	IF “YES” PLEASE EXPLAIN:

Position desired Wage Desired

Employment desired How many hours are you available to work

q Full Time each week?

q Part time

q Temporary

Days Available:

Mon________ Tues_______ Wed________ Thurs________ Fri________ Sat_______ Sun_______

EDUCATION

Name of School	City/State	Did you graduate?	If No, # of years left to graduate	If Yes, date of Graduation	Degree received	Major
High School		q Yes q No
GED		q Yes q No
Other School e.g. Vocational, Trade, Technical		q Yes q No
College		q Yes q No
College		q Yes q No
Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying.

SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your

level of proficiency (basic, intermediate, expert)

OVER à

WORK EXPERIENCE-Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately.

Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments.

Dates Employed (most recent position) From: ______/______ to _____/______ mo yr mo yr	q Full time q Part-time If part-time, # hrs./wk:	Title:
Starting Salary:	Organization Name and Address:
Final Salary:
Supervisor’s Name, Title and Phone #:	Other Reference Name, Title and Phone #:	Contact my current references: q At any time q Only if I am a finalist candidate
Primary duties:		Reason for Leaving

Dates Employed From: ______/______ to _____/______ mo yr mo yr	q Full time q Part-time If part-time, # hrs./wk:	Title:
Starting Salary:	Organization Name and Address:
Final Salary:
Supervisor’s Name, Title and Phone Number:	Other Reference Name, Title and Phone Number:	Contact these references: q At any time q Only if I am a finalist candidate
Primary duties:		Reason for Leaving

Dates Employed From: ______/______ to _____/______ mo yr mo yr	q Full time q Part-time If part-time, # hrs./wk:	Title:
Starting Salary:	Organization Name and Address:
Final Salary:
Supervisor’s Name, Title and Phone #:	Other Reference Name, Title and Phone #	Contact these references: q At any time q Only if I am a finalist candidate
Primary duties:		Reason for Leaving:

Please list two references other than relatives

Name:______________________________________ Name:_______________________________________

Title:_______________________________________ Title:________________________________________

Company:___________________________________ Company:____________________________________

Address:____________________________________ Address:_____________________________________

Phone:_______________________________________ Phone:_______________________________________

:

APPLICATION FORM WAIVER

Please read carefully!

As indication that you have read and understood each sentence, please write your initials in the spaces

provided below.

In exchange for the consideration of my job application by the Town of Cedar Bluff, (hereinafter called

“the Town”), I agree that:

Neither the acceptance of this application, nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements and the like as they may exist from time to time , or other Town practices, shall serve to create an actual or implied contract of employment___ or to confer any right to remain an employee of the Town, or otherwise to change in any respect the employment–at-will relationship between it and the under signed___and that relationship cannot be altered except by a written instrument signed by the Town Council/Mayor___.

Both the under signed and the Town may end the employment relationship at any time, without

specified notice or policies and procedures and such changes may include reduction in benefits.___.

I authorize investigation of all information contained in this application,___ . I understand that the misrepresentation or omission of facts called for is caused for dismissal at any time without any previous notice___. I hereby give the Town permission to contact schools, all previous employers (unless otherwise indicated), references and others and hereby release the Town from any liability as a result of such contact___.

I understand that, in connection with the routine processing of your employment application, the Town may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living___.

Upon written request from me, the Town, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act___.

I further understand that my employment with the Town shall be probationary for a period of ninety (90) days and further that at any time during the probationary period or thereafter, my employment relationship with the Town is terminable at will for any reason by either party___.

APPLICANT SIGNATURE___________________________________________________________DATE_________________________

The Town of Cedar Bluff is an equal employment opportunity employer, we adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with the Town of Cedar Bluff depends solely on your qualifications.

Thank you for completing this application for and for you interest in our business.