Town of Bristol Employment Application P. O. Box 339, Bristol, Maine 04539 Telephone (207) 563-5270 www.bristolmaine.org Applicant Information Full Name: Date: Last First M.I. Address: Street Address Apartment/Unit # City State ZIP Code Mailing Address If different Mailing Address Home Phone: Cell Phone: Email: Date Available: Position Applied for: YES NO Have you worked under a different name? If yes, what name? ___________________________________ YES NO YES NO Are you 18 years or older? Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? How long will your Visa allow you to work in the US? Not YES NO Applicable Will you now, or in the future, require sponsorship for United States employment Visa status? Have you ever worked for the Town of YES NO Bristol? If yes, when? YES NO Have you ever been convicted of a felony or misdemeanor (except minor traffic violations)? Convictions that were completely expunged or were reversed on appeal are not considered convictions for purposes of this question and should not be included or considered in answering this question. A conviction has been “completely expunged” only if no one, including law enforcement, can be permitted access to the record even by court order under the State of Federal Law which was the basis of the expungement. Convictions against a person as a juvenile or youthful offender, youthful offender adjudgements and/or of juvenile delinquency are not considered convictions for purposes of this question and should not be included or considered in answering this question. If yes, explain: Please explain in detail the facts relative to the disclosable conviction(s). An answer of “yes” will not disqualify any applicant for consideration for a job; rather, such information is only relevant in determining whether the conviction is directly related to the job for which you are applying, 1 Last Revised: 11/28/2019 and will be only one of the factors considered in the employment decision and evaluated in terms of the nature, severity, and the date of offense. Education High School: Address: YES NO From: To: Did you graduate? Diploma:: College: Address: YES NO From: To: Did you graduate? Degree: Other: Address: YES NO From: To: Did you graduate? Degree: Please list any special skills, trainings, or certifications pertaining to the job you are applying for that you may have. Please indicate skill level: 1. 2. 3. 4. 5. 6. Additional Comment: References Please list three professional references (excluding relatives) Full Name: Relationship: Company: Phone: Address: Full Name: Relationship: Company: Phone: Address: Full Name: Relationship: Company: Phone: Address: 2 Last Revised: 11/28/2019  Previous Employment Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Military Service Branch: From: To: Rank at Discharge: Type of Discharge: If other than honorable, explain: 3 Last Revised: 11/28/2019  How did you hear of this position? Referral Advertisement Other Who? _______________ ____________________ ___________________ Equal Employment Opportunity Policy It is the policy and practice of the Town of Bristol to abide by all anti-discrimination laws provided for by federal, state, and local statutes and regulations. It is also the policy and practice of the Town of Bristol to provide and promote equal employment opportunities for all applicants and employees. It is also the policy and practice of the Town of Bristol to recruit, hire, train, promote, compensate, and administer all employment practices without regard to race, color, sex or sexual orientation, age, religion, veteran status, liability for military service, whistleblower status, gender identity and/or expression, atypical cellular or blood trait, genetic information (including the refusal to submit to genetic testing or make available the results of a genetic test or on the basis that an individual received a genetic test or genetic counseling), national origin, ancestry, nationality, creed, citizenship, alienage, marital or domestic partnership or civil union status, mental or physical disability, or any other characteristic protected under federal, state, or local law and to affirmatively seek to advance the principles of equal employment opportunity. Furthermore, the Town of Bristol is committed to complying with the Americans with Disabilities Act and similar state laws. If you believe that you need a reasonable accommodation in order to apply for employment or to complete an application for employment due to the fact that you may have a disability, please notify the Town of Bristol within three (3) days of your application of your specific needs for a reasonable accommodation so that we can assist you where appropriate. If an applicant requests an accommodation for purposes of completing the job application process, the Town of Bristol reserves the right to require the application to furnish documentation from an appropriate professional (for example, a doctor, rehabilitation counselor, etc.) confirming that the applicant has a disability or the functional limitations for which a reasonable accommodation is requested. Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any omissions or false or misleading information in my application or interview or other aspects of the hiring process may result in my disqualification from further consideration for employment, or, if discovered after hire; such information may be grounds for the immediate termination of my employment. I understand that employment and continued employment with the Town of Bristol is contingent upon satisfactory consumer reports and criminal background checks. I authorize the Board of Selectmen as well as the Human Resources Department of the Town of Bristol to investigate, verify and discuss all information set forth in my employment application, by contacting my prior employers; colleagues; educational institutions; and other references set forth above, and by any and all other means authorized or permitted by law. I authorize any entity or person named in this application to provide the Town of Bristol with information that may be requested to arrive at an employment decision. I release and agree to hold harmless the Town of Bristol and its subsidiaries and affiliates, and each and all of their respective employees, agents and representatives, from any and all claims, liability or damages that may arise as a result of taking any actions described herein. In addition, I release and agree to hold harmless any and all individuals and entities that provide any information concerning me, whether orally or in writing, in response to a request for such information from the Town of Bristol. If I am employed by the Town of Bristol, I promise to comply with all policies, rules and regulations implemented by the Town as set forth in the Town of Bristol’s personnel policy, employee handbook, or other communications distributed to employees. I understand and agree that if I am hired, my employment with the Town of Bristol will be terminable “at-will”. As an at- will employee, I understand and agree that I have the right to terminate my employment with the Town of Bristol at any time, for any reason, with or without notice, with or without cause, and that the Town of Bristol retains the same rights. If I am hired, I understand that all benefits, policies, procedures and other terms and conditions of employment may be changed by the Town of Bristol at any time, for any reason, with or without notice. I understand that this application, any and all policies, practices, and procedures of the Town of Bristol, and all other communications provided or distributed 4 Last Revised: 11/28/2019 to me by the Town of Bristol, whether written or verbal, before hire or after I am employed, do not constitute or supplement any contract of employment. I further understand that no manager, supervisor, or employee of the Town of Bristol has my authority to enter into any agreement for employment for any specified period of time or to make any agreement for employment other than at-will employment. I understand that if I am hired, I must be able to furnish proof of my identity and eligibility to work in the United States within 72 hours of employment (using forms of document required by the Maine Department of Labor and under Federal Law). I understand that this application will be active only for the position for which I am currently applying. If I would like to be considered for other positions, I understand that I must submit a separate application for those positions. By signing below, I hereby acknowledge that I have read, agree to and accept the above terns and statements. Signature: Date: 5 Last Revised: 11/28/2019