Mukilteo Employment Application Form-2

CITY OF MUKILTEO 4480 Chennault Beach Road, Mukilteo, Washington 98275 (425) 355-4141, ext. 234

APPLICATION FOR EMPLOYMENT Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, creed, national origin, age or the presence of a sensory, physical or mental disability. Reasonable Accommodation -- The City of Mukilteo will provide reasonable accommodation to disabled applicants if requested. Please notify the Personnel Office at least two days prior to the need

Name

POSITION for which you are applying (please print)

DATE STAMP:

_________________________ DATE: ___________________

__________________ ___________________________________________________________ Last) (First) (Middle)

Other Names Known By: _________________________________________________________________ Address ____________________________________________________________________________ (Street) (City) (State) (Zip Code) Telephone Home ___________________ Message ____________________ Work __________________ Social Security # ______ - ______ - ______ (In accordance with the Federal Privacy Act of 1974, disclosure of Social Security Number is voluntary. The SSN will be used for identification purposes to ensure that proper records are obtained.)

Are You A Former City Employee? YES o NO o Relatives Employed By The City: ____________________________________________________________ Type Of Work Desired:

Full-Time o

Part-Time o

Temporary o

Summer o

Do You Possess A Valid Driver’s License: YES o Issuing State: ________

Volunteer o

NO o

Are You Claiming Veterans’ Credit? (Police Officer/Firefighter Applicants only) YES o NO o The City gives Veterans’ Credit (Police Officer/Firefighter Applicants only) as identified by RCW 41.04.010. If you claim Veterans’ Credit, you must complete the Eligibility Worksheet provided in the application packet. Can You, With Or Without Reasonable Accommodation, Perform The Essential Functions Of This Job? YES o NO o High School Graduate? YES o

NO o G.E.D. ? YES o NO o School and Location (for High School or G.E.D.) _____________________________________________________________

EDUCATION Type of School

School and Location

Credits Earned

Major

Type of Degree & Year Obtained

Business or Technical Undergraduate Studies Graduate Studies Examples Certifications Licenses (CDL, etc.) Keyboarding and/or Typing Speed First Aid/CPR

Special Training/Licenses Please List Special Training & Dates Received (especially those required for this job)

Beginning with your present or most recent employment history, including Military Service. Attach additional pages if necessary. Resumes will not be accepted in place of completing this part of the application. Employer Date Employed (MO/YR): From: To: Employer’s Address: Salary Current Salary __________________ Most Recent Position:

Supervisor’s Name:

Reason for Leaving:

May We Contact? If Yes, phone number: YES o NO o Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

Employer

Date Employed (MO/YR): From: To: Salary Last Salary __________________

Employer’s Address: Most Recent Position:

Supervisor’s Name:

Reason for Leaving:

May We Contact? If Yes, phone number: YES o NO o Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

Employer

Date Employed (MO/YR): From: To: Salary Last Salary __________________

Employer’s Address: Most Recent Position:

Supervisor’s Name:

Reason for Leaving:

May We Contact? If Yes, phone number: YES o NO o Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

References (Do not list relatives) Name ____________________________ Address ______________________ Relationship___________________ ______________________

Phone _______________

Name ____________________________ Address ______________________ Relationship___________________ ______________________

Phone _______________

Name ____________________________ Address ______________________ Relationship___________________ ______________________

Phone _______________

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BACKGROUND INFORMATION Are You Legally Entitled To Work In The United States? YES o NO o (As required by the Immigration Reform and Control Act of 1986, you will be required to provide acceptable documentation proving identity and right to work in the United States prior to employment.) Have you been convicted of a felony or released from prison within the last seven (7) years, or been convicted of a misdemeanor other than minor traffic offenses within the past three (3) years? YES o NO o If Yes, Please Explain:___ ____________________________________________________________________________________________ A conviction record will not disqualify you for employment unless such record would reasonably affect your fitness for the job for which you have applied. If I am selected as a finalist applicant, I hereby authorize a City representative to conduct reference and background investigation regarding my work and personal history. I further release and hold harmless from any liability under any and all possible causes of legal action, the City of Mukilteo and all persons with respect to information obtained or provided. To the best of my knowledge the information herein is true and complete. I further understand that falsification of this application will be grounds for elimination from further consideration or, if employed, for dismissal. _________________________________________________ Signature of Applicant

_________________________ Date

AN INCOMPLETE APPLICATION MAY DELAY PROCESSING YOUR APPLICATION OR DISQUALIFY YOU FROM FURTHER CONSIDERATION. The City Of Mukilteo Is An Equal Opportunity Employer

We would appreciate the following information. How did you learn of this position? (Check and complete all that apply.) City Hall Visit

Job Line (425) 355-4141 (ext 410)

Notice Posted At _________________________ Referral by Agency? ______________________

City Web Site (http://ci.mukilteo.wa.us)

Newspaper Name(s)?_____________________________ Job Service Listing _____________________________

Internet Job Listing URL ___________________ Professional Journal ____________________________ Other ________________________________________________________________________________

PLEASE COMPLETE (This section will be separated from the application prior to review) FOR THE PURPOSE OF EFFECTIVELY IMPLEMENTING THE CITY’S AFFIRMATIVE ACTION PROGRAM, WE WOULD APPRECIATE YOUR PROVIDING THE INFORMATION BELOW. THIS IS ENTIRELY VOLUNTARY AND WILL BE KEPT CONFIDENTIAL. IT WILL NOT BE CONSIDERED PART OF YOUR APPLICATION. Please Circle Groups Which Apply To You: Male Female Caucasian African/American Hispanic Asian Native American Other (Please Specify) ___________

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