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2. Position Applied For*
3. Application Date*
   Application Date
5. First Name*
6. Last Name*
8. Phone Number*
10. Email Address*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Shift Preferred*
    -- Select One --123Any
19. Will you accept full time work?*

    1. Yes
    2. No
20. Will you accept part time work?*

    1. Yes
    2. No
22. Expected Pay*
23. Date Available for Work*
    Date Available for Work
25. If necessary, best time to call you

    1. Morning
    2. Afternoon
    3. Evening
29. How were you referred to the City of Justin?*
31. Have you applied for employment with the City of Justin before today?*

    1. Yes
    2. No
32. If yes, please detail date and kind of application
34. Have you been employed with the City of Justin previously?*

    1. Yes
    2. No
35. If yes, please give dates
37. Is this application a request for reemployment following an extended military leave of absence from our Company?*

    1. Yes
    2. No

    If yes, additional information may be requested.
39. If you are under 18 years old, can you provide a work permit if required?*

    1. Yes
    2. No
41. Are you legally eligible for employment in the United States? (If yes, proof is required if hired.)*

    1. Yes
    2. No
43. Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)?*

    1. Yes
    2. No
    3. Need more information about the job’s “essential functions” to respond.

    NOTE: This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.
45. Will you travel if required?*

    1. Yes
    2. No
46. Will you work overtime if required?*

    1. Yes
    2. No
48. If they have been explained to you, are you able to meet the attendance requirements of the position? *

    1. Yes
    2. No
    3. N/A
49. Have you ever been bonded?*

    1. Yes
    2. No
51. Please provide your driver’s license number, if driving is required for this job.
52. State
54. Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our Company?*

    1. Yes
    2. No
56. If yes, please explain
58. Have you ever pleaded “guilty” or “no contest” to, or been convicted of, a crime?*

    1. Yes
    2. No

    NOTE: Answering “yes” to the above question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
60. If yes, please provide date(s) and details:
64. Employment Experience
66. Employer
68. Can we contact this employer?

    1. Yes
    2. No
70. Supervisor/Company Contact Name
71. Contact Phone Number
73. Contact Email Address
75. Address
77. City
78. State
79. Zip Code
81. Job Title
83. Date Employment Started
    Date Employment Started
84. Date Employment Ended
    Date Employment Ended
86. Hourly rate/salary starting
87. Hourly rate/salary ending
89. Work Performed
91. Reason for leaving
93. What did you like most about this position?
95. What were the things you liked least about the position?
97. Employer
99. Can we contact this employer?

    1. Yes
    2. No
101. Supervisor/Company Contact Name
102. Contact Phone Number
104. Contact Email Address
106. Address
108. City
109. State
110. Zip Code
112. Job Title
114. Date Employment Started
     Date Employment Started
115. Date Employment Ended
     Date Employment Ended
117. Hourly rate/salary starting
118. Hourly rate/salary ending
120. Work Performed
122. Reason for leaving
124. What did you like most about this position?
126. What were the things you liked least about the position?
128. Employer
130. Can we contact this employer?

     1. Yes
     2. No
132. Supervisor/Company Contact Name
133. Contact Phone Number
135. Contact Email Address
137. Address
139. City
140. State
141. Zip Code
143. Job Title
145. Date Employment Started
     Date Employment Started
146. Date Employment Ended
     Date Employment Ended
148. Hourly rate/salary starting
149. Hourly rate/salary ending
151. Work Performed
153. Reason for leaving
155. What did you like most about this position?
157. What were the things you liked least about the position?
159. Explain any gaps in your employment, other than those due to personal illness, injury or disability.
161. Have you ever been fired or asked to resign from a job? *

     1. Yes
     2. No
163. If yes, please explain
167. Education Background
169. High School
170. Location
172. Course of study
173. Degree or diploma
175. Did you graduate?

     1. Yes
     2. No
177. College
178. Location
180. Course of study
181. Degree or diploma
183. Did you graduate?

     1. Yes
     2. No
185. Graduate School
186. Location
188. Course of study
189. Degree or diploma
191. Did you graduate?

     1. Yes
     2. No
193. Vocational training/other
194. Location
196. Course of study
197. Degree or diploma
199. Did you graduate?

     1. Yes
     2. No
201. Continuing education
203. Special training or skills
     Languages, machine operation, etc., that would be of benefit in the job for which you are applying.
207. References
209. Name*
210. Title*
212. Phone Number*
213. Email Address*
215. Relationship to you*
216. Years known*
218. Name*
219. Title*
221. Phone Number*
222. Email Address*
224. Relationship to you*
225. Years known*
227. Name*
228. Title*
230. Phone Number*
231. Email Address*
233. Relationship to you*
234. Years known*
238. Applicant statement
     I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws. This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.
240. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
242. Electronic Signature*
243. Date*
     Date
Leave This Blank:


245. 1. Receive an email copy of this form.
246. Email address

     This field is not part of the form submission.

247. Submit

* indicates a required field