Application for Employment
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accomodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) Applied For 

   

Date of Application 

    
Last Name
 First Name
 Middle Name
Street Address
 City
 State
 Zip Code
Social Security Number
 Telephone #
 Mobile/Beeper/Other #
Email
Referral Source: (How did you hear about us?)
If you are under 18, and it is required, can you furnish a work permit?...........................................................
If no, please explain:
Have you ever been employed here before? ......................................................................................................
If yes, give dates and position(s):
Are you eligible for work in this country?.............................................................................................................
Date available for work?  What is your desired salary range?
Type of employment desired             
Driver's license number       State of Issue 
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Note: You are not obligated to disclose the existence of any conviction or arrest records which have been sealed or expunged pursuant to chapter 20, section 2630/12 of the IL Compiled Statutes.
Have you ever pleaded "guilty" or "no contest" to, or been convicted of a felony?........................................
If yes, please provide date(s) and details
Employment History (Starting with your most recent employer, provide the following information.)
Employer #1
Employer  Phone (Include Area Code)  
Address Dates Employed Summarize the nature of the work performed and job duties.
From To
Job Title
Hourly Rate/Salary
Immediate Supervisor Starting
$ Per

  Final
$ Per
Reason for Leaving
May we contact for Reference?    
Employer #2
Employer  Phone (Include Area Code)  
Address Dates Employed Summarize the nature of the work performed and job duties.
From To
Job Title
Hourly Rate/Salary
Immediate Supervisor Starting
$ Per

  Final
$ Per
Reason for Leaving
May we contact for Reference?    
Employer #3
Employer  Phone (Include Area Code)  
Address Dates Employed Summarize the nature of the work performed and job duties.
From To
Job Title
Hourly Rate/Salary
Immediate Supervisor Starting
$ Per

  Final
$ Per
Reason for Leaving
May we contact for Reference?    
Skills and Qualifications (List software titles and years of experience.)
Summarize any skills, licenses or certificates that may assist you in performing the position for which you are applying.
Computer Skills (Check appropriate boxes, include software titles and years of experience.
Word Processing    Years E-mail    Years
Spreadsheet    Years Internet    Years
Presentation    Years Other    Years
Educational Background (Starting with your most recent school attended, provide the following information.)
School (Include City & State)
Years
Completed
Degree or
Diploma
GPA
Class Rank
Major/Minor
References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name
Title
Relationship
Telephone
Years Known
Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at say time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, wtth or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the forgoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.
Signature
Signature:   Date:  
(Checking the Box Below Submits Your Application)
This form can not be submitted until this statement is checked.

  © 2006 City of Rochelle. All Rights Reserved  
  420 North 6th Street, Rochelle, IL 61068  
  Phone: (815)562-6161, Fax: (815)562-3888