City Of Page Application For Employment

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CITY OF PAGE
APPLICATION FOR EMPLOYMENT

697 Vista Avenue, P.O. Box 1180, Page, AZ 86040
(928) 645-4231 FAX (928) 645-4233

The CITY OF PAGE is a DRUG AND HARASSMENT FREE WORKPLACE and A.R.S. 36-601.01 The Smoke-Free Arizona Act a SMOKE FREE WORKPLACE


The policy of the City of Page is to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, gender, religion, national origin, disability, or other protected classifications.




Full Name

Please type your full name.

Position

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Closing Date

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Street Address

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P.O. Box

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City

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State

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Zip

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Home Phone

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Cell Phone

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E-mail

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Please list your previous addresses during the last five (5) years:


List Previous Addresses

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Have you read the job description and essential functions?

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Where did you hear about the vacancy for which you are applying?

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If you selected OTHER above, please list where you heard about us and/or where.
(Please be as specific as possible)

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Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?

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Can you perform these essential functions or the tasks listed on the job description with or without reasonable accommodation?
(Do not answer if you have not read the job description or were not told about the essential job functions.)

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Are you over 18 years of age?

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Are you over 21 years of age or older?

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Are you or have you been employed by the City of Page?

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If yes, dates employed:

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If offered a position with the City of Page, what is the earliest date you can begin employment?

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Are there any hours, shifts or days you cannot or will not work?

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Specify:

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Do you have any relatives working for the City of Page?

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Specify:

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If offered employment, can you provide proof of eligibility to be employed in the United States?

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If applying for a position which requires the use of City of Page vehicles or equipment, a 39 month driving record must be enclosed. Upload file:

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A “YES” answer to the following questions will not necessarily result in denial of employment. The employer will consider all the circumstances, including the date and nature of events which have led to the actions described below. Your written explanation will assist the employer in determining your eligibility, qualifications and suitability for employment.


During the last ten years, have you ever been convicted of, admitted committing, or are you awaiting trial for any crime (excluding only minor traffic violations not involving any allegation of drug or alcohol impairment)? You must answer “YES” even if the matter was later dismissed, deferred, vacated or expunged. If you answer “YES”, you must provide dates of the proceedings, the court where the proceedings occurred, a statement of the accusation against you, and the final disposition of the case(s).

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If “YES,” please explain.

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Have you ever been dismissed (fired) from any job or resigned at the request of your employer, or resigned after being informed that you would be dismissed or an investigation of your behavior was pending? You must answer “YES” even if the matter was later resolved with any form of settlement or severance agreement regardless of its terms. If you answer “YES,” you must provide the date of termination of employment, the name, address and telephone number of the employer(s) and a statement of the alleged reasons for termination.

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If “YES,” please explain.

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WORK HISTORY:
Start with your present or most recent employer and include as many employers as the form allows. May we contact your present employer?

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Most Recent Employer:

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Address:

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Phone:

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Date Started:

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Leaving Salary:

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Per

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Starting Position:

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Position Leaving:

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Supervisor Name and Title:

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Description of Duties:

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Reason for Leaving:

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PREVIOUS EMPLOYER


Previous Employer:

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Address:

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Phone:

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Date Started:

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Leaving Salary:

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Per

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Starting Position:

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Position Leaving:

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Supervisor Name and Title:

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Description of Duties:

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Reason for Leaving:

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PREVIOUS EMPLOYER


Previous Employer:

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Address:

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Phone:

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Date Started:

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Leaving Salary:

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Per

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Starting Position:

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Position Leaving:

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Supervisor Name and Title:

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Description of Duties:

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Reason for Leaving:

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PREVIOUS EMPLOYER


Previous Employer:

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Address:

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Phone:

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Date Started:

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Leaving Salary:

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Per

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Starting Position:

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Position Leaving:

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Supervisor Name and Title:

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Description of Duties:

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Reason for Leaving:

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EDUCATION


High School Name & Location:

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High School Diploma:

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College/University Name & Location:

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College Diploma:

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Degree:

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College/University Name & Location:

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College Diploma:

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Degree:

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Other Training/Education:

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List any equipment that you can operate or special skills that you possess:

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Licenses or Certifications:

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Typing Speed:

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REFERENCES



Reference 1:


Name:

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Phone:

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Position & Business:

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Years Acquainted:

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Reference 2:


Name:

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Phone:

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Position & Business:

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Years Acquainted:

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Reference 3:


Name:

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Phone:

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Position & Business:

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Years Acquainted:

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APPLICANT’S CERTIFICATION AND AGREEMENT

(Please read carefully before signing)

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the City of Page to make an investigation of any of the facts set forth in this application.

Unless indicated otherwise, I hereby authorize the City of Page to investigate my background, references, employment record and other matters related to my suitability for employment. This may include a criminal background check and a check on my driving record. I also authorize my former employers or any third party to disclose to the City of Page all reports and other information related to my suitability for employment, personal or otherwise, without giving me prior notice of such disclosure. I hereby release the City of Page, former employers, and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.

I also realize, if offered a position with the City of Page, my actual employment will be contingent on completion of certain verifications depending on the position I have applied for in the organization. These may include a physical examination, physical ability test, drug screening, credit check, and polygraph testing. The actual items required will depend on the position involved.

I understand that this application is not and is not intended to be a contract of employment.

This application for employment shall be kept on file for a period of time not to exceed 365 days.




Agreement Signature

Must Sign

Date:

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BACKGROUND INVESTIGATION/INFORMATION RELEASE REQUEST

TO WHOM IT MAY CONCERN:

I am an applicant for employment with the City of Page. As part of the hiring process, the City may need to thoroughly investigate my employment background and personal history.

I hereby authorize the City of Page to investigate my background, references, employment record, and other matters related to my suitability for employment. This may include a criminal background check and a check on my driving record. I also authorize my former employers or any third party to disclose to the City of Page all reports and other information related to my suitability for employment, personal or otherwise, without giving me prior notice of such disclosure. I hereby release the City of Page, former employers, and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.

If offered a position with the City of Page, my actual employment will be contingent on completion of certain additional verifications depending on the position for which I have applied. These may include a physical examination, physical ability test, drug screening, credit check, and polygraph testing.




My current address is:

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My current telephone number is:

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My Social Security Number is:

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My date of birth is:

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Any other names used for Driver’s License or employment purposes:

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Name of the state(s) in which a Driver’s License has been issued in the last 39 months:

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Signature

Must Sign

Date:

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Typed or printed name of applicant:
(As it appears on the Driver’s License)

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CITY OF PAGE - EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYMENT SURVEY (10/5/06)

Voluntary Survey Form for Government Employment Monitoring Purposes.

The City of Page is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the City of Page invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, date will not identify any specific individual.

This voluntary information sheet is separated from your employment application and is kept in a confidential file for statistical use only.

If offered a position with the City of Page, my actual employment will be contingent on completion of certain additional verifications depending on the position for which I have applied. These may include a physical examination, physical ability test, drug screening, credit check, and polygraph testing.




Date:

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Position Applied For:

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Name:

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Signature

Must Sign

Veteran:

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Disabled Veteran:

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Disabled Individual:
(Any person who has a physical or mental impairment substantially limiting one or more of his/her major life activities)

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Gender:

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Ethnic Origin:

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Native Hawaiian or Other Pacific Islander:

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DRUG AND ALCOHOL TESTING ACKNOWLEDGMENT

If offered employment, the below named individual, understands they will be subject to pre-employment drug and alcohol testing, post accident drug and alcohol testing and reasonable suspicion drug and alcohol testing, and random testing (CDL holders) as per the City of Page Employee Drug Free Workplace Policy.




Applicant Name:

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Date:

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Applicant Signature

Must Sign

How should we contact you?



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