pa

F",,\ I~III""

PI=

print

5103)

PersonnellHuman

~ ink (preferably

City of SOCOITO

bl.~Ck)or use Iypewriter

124 S. Horizon

All Equal Opportulliry Employer

Numberofatt:lchmenrs.-

Resource Department

Socorro. TX 79927

Application for Employment

915-853-291.

www.socorrotexas.org

As a means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by caJJ.ingthe Personnel Office at 858-2915

Employees of the City aild applicants for employment sball be afforded equal opportunity in all aspectS of employment without regard to race, color, religion, poliriCll :1ffiliMion, national origin, disability, marital status, gender or age.

Position applied for

Today's Date

one per applic:lrion

Failure to submit social securiry Tnlmber on this form will not prohibit employmem consideration. Social seC"..lrirynumber may be required on cJtherforms prior to employmem.

Social Security No. Full legal name

Fim

Home Phone (

Middle

)

Business Phone

Address

E-mail address City

Stne

o Yes ONo

Zip Code

Are you at least 18 years of age?

Do you have any relatives (including in-laws) CUITentlyemployed with the City of S.ocorro? DYes I£Yes, please state the following Name Relationship Department and Location

ONo

Have you ever been convicted of or pled guilty or no contest to, or entered into a pretIial diversion or other deferral program for a crime (felony or misdemeanor) other than a mIDor traffic violation? (NOTE: Convictions for reckless driving and Dill are not considered minor traffic violations) Yes No If yes or unsure, descn"be in detail (Not all convictions will bar employment. Each case will be reviewed on its own merit.

E~~LOYMlliNT~O&~TION Have you every applied to or worked for the City of Socorro?

0

Yes

Salary expectations:

0

Full-time

Position Status:

0

Check which shift you willaccept 0 Day 0 Evening 0 Night 0 Rotating Are you willing to accept employment, which requires you to travel?

?

0

No If yes-state date

0

0

Part-time

0

Temporary

Weekends Hrs:

Yes

0

No

Do you have your own transportation?

No date if you are availableas soon as

When willyou be able to start work? .

yougivetwo (2) weeksnotice. RROFESSIONAL REFERENCES Please complete this entire secTion, even should be previous supervisors.

ifyou

have submitted your resume. All Professional References

Applicant Name

Applk:ltion for Employment Page 2 '. ....

Name

Name

.-

Name

Professional Relationship

Telephone Number

Professional Relationship

Telephone Number

Professional Relationship

Telephone Number

SKJLLS

Typing WPM

Data Enrry

IE MlPCnvlacintosh

Programming Languages

Spread Sheer (LOtus, Excel, erc)

Word Processing (Word Perfect, etc.)

PBX

Other

GENERAL INFORiVlAnON Are you able to perform the essentialjob functions of the position for which you are applying with or without reasonable accommodations? 0 Yes 0 No Please provide any other information thaI you feel is pertinent to your ability to perform the job for which you are applying

GENERAL TERlVIS AL'IDCONDmONS

Please read carefully.

1986 Immigrations and Reform and Control Act The City takes seriouslytheir responsibilityunder the Immigration Reform and Control Act of 1986 to hire only persons authorizedto work in the United States. As a condition of employment,I understand that I will be required to furnishproof of my identity and authorityto work in the U.S. as required by law. Are you a D.S Citizen,Permanent~esident, Temporary Resident (answer "no" if you a nonimmigrant such as a F-l or J-l student, H-IB worker, etc.,) A5ylee,or Refugee? Yes No If yes; please explain (Do not attach any documentation

Signature

at this time)

Date

Pre-Employment Drug Screening Consent and Authorization The City of Socorro has adopted a drug-free workplace policy. The City requires all:final external applicants to submit to a urinalysis for drugs and drug metabolites. The urinalysis will be conducted by an authorized testing facility and you must-authorize the release of the urinalysis report result to the City. These results will be used solely to evaluate your elig'ibilityfor employment with the Cit and will be kept confidential.

.

Applicant Name

Application for Employment

Page3

'.

Refusal to sign this authorizationor to submit to the urinalysis willrender you ineligiblefor further employment consideration. I, the undersigned have read and W1derstandthis consent and herebyauthorize the release of the results of the urinalysisto the City ofSoCOITO for the above stated purposes. I further understand that my employmentis contingem upon the receipt ofa negative(i.e. free of illegalor unlawful drug use) drug result. I will be provided a copy of this consent and release upon request. Print Name

Signature of Applicant

02

03

Date

Daytimephone

Signature of Parent or yuardian. if applicantis a minor Education a. Checkhighestgradecompleted 01

Date

04

05

06

07

08

09

010

0

b. If you did not complete high school, do you have a high school equivalency diploma?

c. Checknumberofyearsof posthighschooleducation 01 Hrs Name and Location ofInstirution

I

l.

I I

2. 3.

d.

I

,

Degree Received

02

03

04

05

06

011 0

0 12 No

0

Yes

7

Minor

Majoror Specialty

Dates Attended

I

I

I

I I

I I

I

If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date.

E.."XPERIENCE - Use blank paper for additional space. Starting with the most r~<>nt,describe ALL paid, military and applicable voluntary experience. Highlight your knowledge; skills and abilities, which best demonstrate your qualifications for this position. You many list significantly different jobs within the same organization as separate items. May we contact your present supervisor? Yes 0 No

0

Duties:

a. Job Title Employer Address Phone Type of busmess

Immediatesupervisor Title

Salary(start). Dates (mo/yr) FuIl-time

b. Job Tide Employer

(end) .to (mo/yr) Part-time Hr/wk -

Number and titles of employeesyou supervise Equipment used Reason for leaving Your name if differentfrom present Duties:

._~'.. .. --

. :........-

. Applicant Name

AppliC3rion for Employment Page.!

",

Address Phone Type of business Immediate'supervisor Title

Salary(start). Dates (mo/yr) Full-time

Number and titles of employees you supervise

(end) ,to (mo/yr) Part-time Hr/wk -

Equipment used Reason for leaving Your name if different ITompresent Duties:

C. Job Title Employer Address Phone Type 0f business Immediate supervisor Title Salary (start) ,

Dates (mo/yr) Full-time

(end) ,to (mo/yr) Part-time Hr/wk

Number and titles of employeesyou supervise

-

d. Job Title Employer Address

Equipment used Reason for leaving Your name if differentITompresent Duties:

"

Phone Type 0fbusiness Immediate supervisor Title (end) Salary (Start) Dates (mo/yr) .to (mo/yr) Full-time Part-time Hr/wk

e. Job Title Employer Address Phone Type of business Immediate supervisor Title (end) Salary (start) Dates (mo/yr) ,to (mo/yr) Full-time Part-time Hr/wk f. Job Title Employer Address

Number and titles of employees you supervise

Equipment used Reason for leaving Your oaI?e if differentfrom present Duties:

Number and titles of employeesyou supervise Equipment used Reason for leaving Your name if different ITompresent Duties:

.

ApplicatiolJ for Employment Page S :.-.

Applicant Name

Phone

Type of business Immediate supervisor Title -(end) Salary (start) Dates (mo/yr) .to (mo/yr) Part-time Hr/wk Full-time

Number and titles of employees you supervise

Equipment used Reason for leaving Your name if different:trompresent

Authorization I specificallyauthorize the Cityof Socorro to investigate my background, includingbut not limited to any and all references, interviewswith third parties, familymembers, mends, neighbors,businessassociates and financial sources, availablecriminaland otherjudicial records, and my credit record where applicable to the position(s) for which I am applyingand consistentwith applicable law. Further, I understand that a consumer investigativereport may be made to obtain informationabout my educatio~ character, or reputation. A:3required by the Fair Credit Reporting Act (15 USO-Section1681,et seq.), I understand that I will be notified ifsuch an investigativereport is made and I will have tlie right to make a written request within a reasonableperiod oftme for a complete disclosure of info~tion concerningthe nature and scope the investigation. Do you have a valid driver's license?

0

Yes

If "No", do you have a valid state ID card?

0

ONo Yes

If "Yes", list State and License #:

ONo

If "Yes", list State and ill #

A:, noted above, the City may use your credit history as hiring criteria. The City uses a credit bureau as the source for this information. In the event that you become a final candidate for a position and we obtain your credit history, the law requires us to provide you with a copy, if you so desll-e. Please indicate if you would like a copy. .,

No, I do not want to receivea copy of my credit history Yes, I would like a copy of my credit history as provided by the credit bureau, if it is requested. send it to the address that appears on the front of this application.

Please

If I have questions about the credit report, I understand that I must contact the credit bureau directly for information or to make any changes. I further understandthe City of Socorro is not required to explain in detail my credit history or how any investigativereport is used I the employment process. This authorizatio~ in origjnalor copy fo~ shall be valid for this and any future reports that may be requested. I understand that my employmentis c.onditioned0 the approval by the City of Socorro of the results of these investigations.

Signature

Date

Applicant's Certification and Release of Liability I hereby certify that the information I have provided on this application and its attachments is true and correct to the pest of my knowledge and that no attempt has been ~e by me to conceal any pertinent information. I understand that any error or o~sion of information may constitute grounds for denial of employment or subject me to termination at any time during my employment. -

.

Application for Employment P:1ge6 ..:'

Applicant

Name

Allyapplicant who knowinglyfalsifieshis or her application will be ineligibleto apply for any city position for a period of two years (2) ye3fSfromthe date the falsifiedapplication was submitted. Additionally,the applicant's name will be removed fonn any eligiblelist on which it cUITentlyappears. Unless otherwise noted on this application,I authorize my previous employers,references, and other persons or institutionsnoted on this applicationto provide the City of Socorro with any informationthey may have regarding me, includingbut not limitedto employmenthistory, including salary infonnation. I agree to hold harmless the City of Socorro and their agents, associatesand employees and all persons supplyingthe intonnation to the City and their agents, associates and employees,for any and all liabilitiesarising out of their investigationof my application for employment. I understand that my applicationis beingconsidered only for the specificposition for which I have applied, and that my application will remam active for no more than a year, three hundred and sixty five days (365) day. IfI am not hired for this position and subsequentlybecome interested in any furorejob opportunities that me become available,I understand that I will n~edto reapply. I funher agree tha~ ifhired, I will be required to comply with al rules, policies, and regulations of the City of Socorro, I Wlderstandthat the City's benefits,rules, policies and regulations may be changed, modified, deleted or supplementedby the City at any time. No oral or other representationsmade regardless of who makes them, shall be effectiveto modify these terms and conditions so as to create anyagreementof employment, either expressed or implied. I agree that I am not guaranteed any term of employmentfor any specifiedperiod of time or contrary to the terms and conditions stated herein. A photocopy of this authorization shall have full force and effect of the origIDaL .f

Signature of Applicant

Date

.

Applicant Name

Applic:ariOD for Employment P:1gc 7 ".'.

NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGA TION I authorize the City of SOCOITO and its agents to investigate my background in connection with my application for employment and/or volunteer service. I understand that this investigation may include, but may not be l.imitedto, my personal history, employment history, driving record educational background, and any military or criminal records. I release the City of SOCOITO, all fonner and CUITentemployers, educational institutions and other persons or agencies providing information about me ITomall liabilityfor damages arising ITomthe furnishingof such information. This authorization, in original and copy form shall be valid for this and any furore reports and updates that may be requested. PLEASE PRINT CLEARLY FULL NA1YtE

OTHER NAMES USEDIDATES CURRENTADDRESS: SOCIAL SECURlTY #

PHONE DATE OF BIRTH DRIVER'S LICENSE #

STATE ISSUED

STATE ID # (if applicable) STATE ISSUED NAME AS IT APPEARS ON YOURDRIVER'S LICENSE OR STATE ID:

LIST ALL ADDRESSES FOR PAST 7 YEARS (If more room is needed, please use back of form) Street Name

City

State

DATES: From

To

Street Name

City

State

DATES: From

To

Street Name

City

State

DATES: From

To

***MAY WE CONTACT YOUR CURRENT ENfPLOYER ***HAVE YOU EVER BEEN CONVICTED OF A CRIME -

.'

SIGNATURE:

YES

NO

YES -

NO

DATE

NOTICE: YOU HA \IE HiE RIGHT TO DISCLOSURE OF THE NATIJRE AND SCOPE OF THE INVESTIGATION WRITTEN REQUEST TO TIlE CITY OF SOCORRO PURSUANT TO THE OPEN RECORDS ACT.

BY NW<.JNG A

. ' Applicant Name

Applic:ttion for Employment . "age S

cJIY OF SOCORRo tEXAS AUTHORIZATION TO REVIEW CREDIT REPORT r.ais is to notify you that the City ofSOCOITOwill be obtaining a copy of your COIlS1.UTIer credit report from one or nore credit reporting agencies

)lease sign below:

,".10

authorize the City of Socorro to obtaina copy of my consumer credit report from one or more credit reporting .gencles.

,19Dature

Date .' .,

.

Applicant Name

\ppliatioo' for Employment ':1gC9

Gl'TY

OF SOCORRo fEXAS

Pursuant to federal regulatioDS, we collect responses to the questions below for record keeping purposes. This infonnation .v:illNOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, ::olor, sex, age~national origin, religion, or disability.

.:heck: the block for the racial or ethnic group with ,vhich you identify: White (includes Arabian) :J Black (includes Jamaic:m, Bflhamians and other Carribbeans of AiiicUi but not Hispanic

:J

or Arabian descent)

.

:J Hispanic

(includes persons ofMexic:m. Pueno Ric:m, Central or South Ameri= or other Spanish origin or culture) ::J Asian & Asian Ameri= (includes Pakistanis. fndians & Pacific Islanders) ::J Americ:1I1 fndians (includes Alaskans)

Check the block for the highest level of education you have completed (check only one): ~s than 8th grade Completed 8th grade Attended high school High school graduate or equivalent Attended college and/or associare degree College graduate Attended graduate school Master's degree Graduate stUdy beyond master's requirements Ph.D. or professional degree

o o o o o o o o o

o

Check the appropriate block:

o Female

o Male

Please indicate your date of birth: Position applied for: Position number:

FOR OFFICE USE ONLY EE0 Category:

Howdid you find out about tbis employmentopportunity? Please specify one referral only and be as specific as possible.

~ ~

Newspaper'" Radio/TV*

~ Walk-in

0 0 0

Internet

StaffingAgency Job Posting

o Personal Referral o Job Fair o Otber (please specify)

*specify name of newspaper or other media

-! -! -