Application for Employment

Please fill out form completely and submit for employment consideration.

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin or handicap. We are an equal opportunity employer.

Personal Information

Date:

Last Name:

First Name:

Middle Initial:

Telephone No:

Present Address

Street:

City:

State:

Zip:

Email (where the HBPW can send information to you):

Are you over 18 years of age?

Can you be legally employed in the U.S.?

Position(s) applied for

1.

Rate of pay expected $

Per

2.

Rate of pay expected $

Per

How did you learn of this opening?

Do you want to work:

If hired, on what date could you start?

Have you worked for or applied with us before?

If yes, when?

Why are you interested in working for Holland Board of Public Works?

Have you been convicted of a crime, excluding misdemeanors and summary offenses? (Conviction of a crime will not automatically result in denial of employment.)

If yes, explain when, where and nature of offense

Are there any felony charges pending against you now?

If yes, please explain.

Business References (Supervisor/Manager)

Name and Occupation

Address or E-mail

Phone Number

Name and Occupation

Address or E-mail

Phone Number

Name and Occupation

Address or E-mail

Phone Number

Name and Occupation

Address or E-mail

Phone Number

Education

High School

Name of Educational Institution

City/State

Curriculum or Degree

Did you graduate?

Trade School or College

Name of Educational Institution

City/State

Curriculum or Degree

Did you graduate?

Advanced Degree(s)

Name of Educational Institution

City/State

Curriculum or Degree

Did you graduate?

Professional Certifications

Name of Educational Institution

City/State

Curriculum or Degree

Did you graduate?

Other

Name of Educational Institution

City/State

Curriculum or Degree

Did you graduate?

Military

Period of Service: (Start Date)

Period of Service: (End Date)

Branch

Rank

Duties

Employment Record

Please account for all periods of time. Add additional pages if necessary.

Current or Most Recent Employer

Company Name

Employed From: (Start Date)

Employed To: (End Date)

Pay/Rate (Start)

Pay/Rate (Final)

Address

Phone # or E-mail

Supervisors Name

Job Title and Major Duties

Reason for Leaving

Do we have your permission to contact the employer listed above?

Previous Employer

Company Name

Employed From: (Start Date)

Employed To: (End Date)

Pay/Rate (Start)

Pay/Rate (Last)

Address

Phone # or E-mail

Supervisors Name

Job Title and Major Duties

Reason for Leaving

Previous Employer

Company Name

Employed From: (Start Date)

Employed To: (End Date)

Pay/Rate (Start)

Pay/Rate (Last)

Address

Phone # or E-mail

Supervisors Name

Job Title and Major Duties

Reason for Leaving

Supplemental Information

If there are other experiences, skills, or qualifications which you believe would specifically fit you for work with Holland Board of Public Works, please include them on a separate sheet of paper.

Applicant's Certification and Agreement - Please Read Carefully

I hereby certify that all statements on the Application for Employment are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed will be just cause for immediate dismissal.

I authorize the references listed in this Application for Employment, and any prior employer, educational institutions, or any other persons or organizations to give Holland Board of Public Works any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise. I hereby waive written notice that employment information is being provided by any person or organization. I understand that such information may contain my social security number. I release all parties from all liability for any damage that may result from furnishing that information to Holland Board of Public Works.

If I am disabled and require an accommodation to perform the job, I must notify Holland BPW Human Resources Director of that need in writing. Failure to do so may bar me from alleging that Holland Board of Public Works has not accommodated me as required by law.

I hereby authorize Holland Board of Public Works to secure criminal conviction history should it determine that it is necessary to do so.

I understand that I may be required to take a physical exam before I start working. I also understand and authorize Holland Board of Public Works with its designated agent(s) to withdraw specimen(s) of my blood, urine, or hair for chemical analysis. The purpose of the analysis is to determine or exclude the presence of alcohol, drugs or other controlled substances. I understand that decisions concerning my employment will be made as a result of this test.

Signature (retype name)

Attach a Cover Letter

Attach a Resume

Confirm: