Columbus Day News

APPLICATION FOR EMPLOYMENT INDIAN RIVER SHORES PUBLIC SAFETY DEPARTMENT 2001 65th Avenue Indian River Shores, FL 32967 (772) 231-2700 INSTRUCTIONS: Answer all questions. If a question does not apply to you, insert N/A in the space. PLEASE PRINT PERSONAL Name (Last, First, Middle Initial) ____________________________________________________________________________________ Present Address __________________________________________________________________________________________________ Street City State Zip Permanent Address ________________________________________________________________________________________________ Street City State Zip Phone No. ( ) ________________________________ Cell No. ( ) ________________________________________________ Email Address __________________________________________________________________________________________________ Social Security No. _______________________________________ Date of Birth __________________________________________ Are you a citizen of the United States? Yes ____ No ____ If no, are you authorized to work in the U.S.? Yes ____ No ____ Have you ever filed an application with this department before? Yes ____ No ____ If yes, give date ____________________ Are you now or have you ever been employed by this department? Yes ____ No ____ If yes, give date ____________________ Do you have any friends or relatives working for this department? Yes ____ No ____ If yes, state name & relationship ____________________________________________________________________________________________________________________ Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation? _____ Yes _____ No If no, describe the accommodation required: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Driver’s License No. _________________________________________ State ______________________________________________ CDL? _____ Yes _____ No Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes _____ No _____ If yes, state the nature of the offense(s), when and where convicted, and disposition of the case: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ EMPLOYMENT EXPERIENCE List below all present and past employment starting with your most recent employer: Employer ___________________________________________________________ Phone No. ( ) __________________________ Address __________________________________________________________________________________________________________ Supervisor ___________________________________________________________ Dates Employed __________________________ Job Title _____________________________________________________________ Salary __________________________________ Duties Performed __________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Reason for Leaving ________________________________________________________________________________________________ Employer ___________________________________________________________ Phone No. ( ) __________________________ Address __________________________________________________________________________________________________________ Supervisor ___________________________________________________________ Dates Employed __________________________ Job Title _____________________________________________________________ Salary __________________________________ Duties Performed __________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Reason for Leaving ________________________________________________________________________________________________ Employer ___________________________________________________________ Phone No. ( ) __________________________ Address __________________________________________________________________________________________________________ Supervisor ___________________________________________________________ Dates Employed __________________________ Job Title _____________________________________________________________ Salary __________________________________ Duties Performed __________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Reason for Leaving ________________________________________________________________________________________________ May we contact the employers listed above? Yes _____ No _____ If no, indicate which one(s) you do not wish us to contract: ____________________________________________________________________________________________________________________ EDUCATION School Name Location No. Years Completed Degree ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ References: Give the names of three persons not related to you, whom you have known for at least one year. Name Address Phone Number ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ AUTHORIZATION I authorize the Indian River Shores Public Safety Department to thoroughly investigate my references, work record, education and other matters related to my suitability for employment. I further authorize the references I have listed to disclose to the Indian River Shores Public Safety Department any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from any and all liability for any damage that may result from furnishing same to the Indian River Shores Public Safety Department. I understand that any misrepresentation or omission of facts from this application may be cause for rejection or, if employed, termination. I understand that in the event I am offered employment with the Indian River Shores Public Safety Department, I may be required to submit to a pre-employment drug screen as a condition of employment. I understand that this application is not a promise of employment and that I am not obligated to accept employment with the Indian River Shores Public Safety Department if offered. I certify that I have read and understand the preceding information and that all information contained in this application is true and complete to the best of my knowledge. Signature ________________________________________________________________________ Date __________________________ FAILURE TO SIGN WILL DISQUALIFY APPLICATION