Application for Employment

Town of Glocester
1145 Putnam Pike - PO Box B
Chepachet, RI 02814-0702

Position(s) Applied For:	Date of Application:
How Did You Learn About Us? Choose One Advertisement Employment Agency Relative Friend Inquiry Other	If other, please specify:

Last Name:

First Name:

Middle Name:

Street Address:		Apt No:
City:	State:	Zip:
Telephone Number(s):

	Best time to contact you at home.
Yes     No	If you are under 18 years of age, can you provide required proof of your eligibility to work?
Yes     No	Have you ever filed an application with us before?
	If yes, give date.
Yes     No	Have you ever been employed with us before?
	If yes, give date.
Yes     No	Do any of your friends or relatives, other than spouse, work here?
Yes     No	Are you currently employed?
Yes     No	May we contact your present employer?
Yes     No	Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.)
	Date available for work.
	What is your desired salary range?
	When are you available to work? (Check all that apply):
	Full Time - 1st Shift  Full Time - 2nd Shift  Full Time - 3rd Shift  Part Time - Mornings  Part Time - Afternoons  Part Time - Evenings  Temporary          Dates Available  From:   To:
Yes     No	Are you currently on ''lay-off' status and subject to recall?
Yes     No	Can you travel if a job requires it?

EDUCATION

	Name & Address of School	Course of Study	No. of Years Completed	Diploma/Degree
Elementary School
High School
Undergraduate College
Graduate / Professional
Other (specify)

Describe any specialized training, apprenticeship, skills and extra-currictilar activities.

Describe any job-related training received in the United States military.

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer #1:
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Employed:	From    To
Hourly Rate/Salary:	Starting    Final
Work Performed:

Employer #2:
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Employed:	From    To
Hourly Rate/Salary:	Starting    Final
Work Performed:

Employer #3:
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Employed:	From    To
Hourly Rate/Salary:	Starting    Final
Work Performed:

Employer #4:
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Employed:	From    To
Hourly Rate/Salary:	Starting    Final
Work Performed:

If you need additional space, please continue in the field below:

List professional, trade, business or civic activities and offices held: You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other  protected status.

ADDITIONAL INFORMATION

OTHER QUALIFICATIONS Summarize special job-related skills and qualifications acquired from employment or other experience.

SPECIALIZED SKILLS Check skills and/or equipment operated.
Yes     No	Terminal
Yes     No	PC/MAC
Yes     No	Typewriter   WPM
Yes     No	Spreadsheet
Yes     No	Word Processing
Yes     No	Shorthand   WPM
	Production/Mobile Machinery (list)
	Other (list):

State any additional information you feel may be helpful to us in considering your application.

NOTE TO APPLICANTS DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Yes     No	Can you perform the essential functions of the job for which you are applying, either with or without a reasonable accommodation?

REFERENCES
1.	Name:	Phone:
	Address:
2.	Name:	Phone:
	Address:
3.	Name:	Phone:
	Address:

APPLICANT'S STATEMENT

By submitting this application, I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be nessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days.

Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an ''at will'' nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this ''at will'' employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

The Town of Glocester does not discriminate on the basis of race,
color, national origin, sex, religion, age or disability. EOE.

The Town of Glocester is an Equal Opportunity Employer.