CLEAR FORM Human Resources www.rogersar.gov 301 W. Chestnut – Rogers, AR 72756 • (479) 621-1117 – (479) 631- 2767 fax The Employment History section of this application must be completed. Incomplete applications will not be considered. Application for Employment Position applied for must be specified. Please Print Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the applicant and/or interview process should notify a representative of the Human Resources Department. Position(s) applied for ________________________________________________ Date of application ______________ POSITION MUST BE SPECIFIED Referral Source: □ Advertisement □ Employee □ Relative □ Government Employment □ Walk-in □ Private Employment Agency □ Other ______________________ Type of employment desired: □ Full-time □ Part-time □ Temporary □ Seasonal Name ______________________________ __________________________ _____________________________ Last First Middle Address ______________________ __________________ ____ _________ Social Security # _________________ Street City State Zip (Law Enforcement only) Telephone # _________________ Alternate Phone # __________________ E-mail ______________________________ Date available for work ______________ What is your desired salary range? _________________________ May we contact you at work? □ Yes □ No If yes, work number and best time to call? ______________________________ If necessary; best time to call you at home is? ______________________________ If you are under 18 and it is required can you furnish a work permit? □ Yes □ No Have you submitted an application before? □ Yes □ No Are you legally eligible for employment in this country? □ Yes □ No Will you travel if the job required it? □ Yes □ No Are you able to meet the attendance requirements of the position? □ Yes □ No Will you work overtime if required? □ Yes □ No Have you ever been convicted of a crime? □ Yes □ No If so, please provide dates and details.___________________________________________________________ Answering “yes” to these questions 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. Driver’s license number if driving is an essential job function. _________________________State __________ AN EQUAL OPPORTUNITY EMPLOYER EMPLOYMENT HISTORY Starting with you most recent employer, assignments or volunteer activities, provide the following information. Employer Telephone # From: Month Year To: Month Year Date Employed Street Address City State Compensation (Starting) Starting Job Title/Final Job Title $ per _______________________________________________________________________________________________________________________________________ Immediate Supervisor and Title _______________________________________________________________________________________________________________________________________ Reason for Leaving Compensation (Final) May we contact for reference? Yes No $ per _______________________________________________________________________________________________________________________________________ Summary of job responsibilities: _______________________________________________________________________________________________________________________________________ Employer Telephone # From: Month Year To: Month Year Date Employed Street Address City State Compensation (Starting) Starting Job Title/Final Job Title $ per _______________________________________________________________________________________________________________________________________ Immediate Supervisor and Title _______________________________________________________________________________________________________________________________________ Reason for Leaving Compensation (Final) May we contact for reference? Yes No $ per _______________________________________________________________________________________________________________________________________ Summary of job responsibilities _______________________________________________________________________________________________________________________________________ Employer Telephone # From: Month Year To: Month Year Date Employed Street Address City State Compensation (Starting) Starting Job Title/Final Job Title $ per _______________________________________________________________________________________________________________________________________ Immediate Supervisor and Title _______________________________________________________________________________________________________________________________________ Reason for Leaving Compensation (Final) May we contact for reference? Yes No $ per _______________________________________________________________________________________________________________________________________ Summary of job responsibilities _______________________________________________________________________________________________________________________________________ Employer Telephone # From: Month Year To: Month Year Date Employed Street Address City State Compensation (Starting) Starting Job Title/Final Job Title $ per _______________________________________________________________________________________________________________________________________ Immediate Supervisor and Title _______________________________________________________________________________________________________________________________________ Reason for Leaving Compensation (Final) May we contact for reference? Yes No $ per _______________________________________________________________________________________________________________________________________ Summary of job responsibilities _______________________________________________________________________________________________________________________________________ SKILLS & QUALIFICATIONS □ Word □ Excel □ Access □ PowerPoint □ Internet Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying: ____________________________________________________________________________________________________________ AN EQUAL OPPORTUNITY EMPLOYER Educational Background (if job related) Starting with you most recent school attended, provide the following information. School (Include City & State) Number of Years Achieved GPA Major Minor Completed Class Rank GED Diploma Degree GED Diploma Degree GED Diploma Degree References List name and telephone number of three business/work references. Please do not list family members. Name Title Relationship to Telephone Years Known Candidate Additional Information List professional, trade, business or civic associations and any offices held. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status. Organization Offices Held List special accomplishments, publications, awards, etc. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any similarly protected status. __________________________________________________________________________________________________ List any additional information you would like us to consider: __________________________________________________________________________________________________ List names and relationship of any relatives currently employed by the City of Rogers: __________________________________________________________________________________________________ AN EQUAL OPPORTUNITY EMPLOYER APPLICANT STATEMENT I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct. 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, resume 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 such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 60 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 to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer’s service, whenever it is discovered. NOTICE: All applications and resume submissions are subject to public disclosure upon request under the Arkansas Freedom of Information Act. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant ___________________________________________________ Date _____________________ PRINT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER