CITY OF GLEN DALE, 402 WHEELING AVENUE, GLEN DALE, WV 26038

304-845-5511

EMPLOYMENT APPLICATION

Applications are considered for all positions without regard to race, color, religion, sex, national

origin, age, marital or veteran status, or in the presence of a non-related medical condition or handicap.

Name:_______________________________________________________ Date:___________________

Address:___________________________________________________ Phone #___________________

City:_____________________ State:______ Zip:__________ Social Security #_______________________

Date of Birth:___________________________

Are you a citizen of the United States of America? [ ] Yes [ ] No

Have you ever  been convicted of a felony or misdemeanor? [ ] Yes [ ] No

If yes, please explain: _______________________________________________________________

Have you applied here before? [ ] Yes [ ] No; When?____________________

What position are you applying for?____________________________________________________

When can you start ________________________________________

[ ] Full time [ ] Part time [ ] Temporary [ ] Other__________________

EMPLOYMENT EXPERIENCE

Start with your present job or last job. Include military assignments and other

volunteer activities. Exclude organizational names which indicate race, color,

religion, sex, or national origin.

Employer 1: __________________________________________________________________________

Address: __________________________________  City:________________ State:_____ Zip: _________

Phone #________________ Supervisors’ Name: _____________________________________________

Job Title:______________________ Reason for leaving: _______________________________________

Dates of Employment: From:_________ To:__________ Salary or Hourly rate:______________________

Employer 2:__________________________________________________________________________

Address:___________________________________ City:________________ State:_____ Zip:__________

Phone #________________Supervisors’ Name:_____________________________________________

Job Title:______________________ Reason for leaving:_______________________________________

Dates of Employment: From:_________ To:__________ Salary or Hourly rate_____________________

Employer 3__________________________________________________________________________

Address:___________________________________ City:________________ State:_____ Zip:__________

Phone #________________Supervisors’ Name_____________________________________________

Job Title:______________________ Reason for leaving:_______________________________________

Dates of Employment: From:_________ To:__________ Salary or Hourly rate:______________________

EMPLOYMENT APPLICATION PART 2

EDUCATION

Schools/Collages Attended: # Years Year Grad. Degree

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Describe any special qualifications for this job:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Drivers License #_______________________________ State:__________ Expiration:_____________

Do you have a valid C.D.L. License: Yes [ ] No [ ]

Has your license ever been suspended: Yes [ ] No [ ]

If yes, please explain: __________________________________________________________

Are you a veteran of the U.S. Military service? [ ] Yes [ ] No

I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize

investigations of all statements contained in this application for employment as may be necessary in

arriving at an employment decision. I understand that this application is not intended to be a contract of

employment. In the event of employment, I understand that false or misleading information given on

my application or interview may result in termination.

Signature:__________________________________________ Date:_____________________

For Personnel Department only

Remarks_________________________________________________________________________

________________________________________________________________________________

______________________________________Interview report by__________________________

Accurate Credit Bureau fax 626 398-0642

I wish to order [ ] Credit Report [ ] DMV Records [ ] Reference Verification [ ]Criminal Records

RELEASE OF INFORMATION

To whom it may concern:

    I hereby authorize any representative of The City of Glen Dale bearing this release to obtain

information from your files or other sources pertaining to my personal back round including, but

not limited to, academic, athletic, achievement, attendance, personal history, disciplinary action,

medical, credit or any other records you may have regarding me. I hereby direct you to release

such information upon the request of the bearer. This release is executed with the full knowledge

and understanding that the information is for the official use by The City of Glen Dale consent is

granted for The City of Glen Dale to furnish such information as is described above, to third

parties in the course of fulfilling its official responsibilities with regard to my application for

employment. I hereby release you, the institution or establishment which you represent

including its officers, employees, and related personal, both individually and collectively, for

any and all liability for damages of whatever  kind, which may at any time result to me, my heirs

family or associates because of compliance with this authorization and request to release

information, or any attempt to comply with it. Should there be any question as to the validity

of this release, you may contact me as indicated below.

FULL NAME: ______________________________________________________________

                           (TYPED OR PRINTED)

CURRENT ADDRESS: ______________________________________________________

_________________________________________________________________________

DATE OF BIRTH: __________________________________________________________

SOCIAL SECURITY NUMBER: ______________________________________________

TELEPHONE NUMBER: ___________________________________________________

DATE: __________________________________________________________________

_______________________________________________________________________

(SIGNATURE)

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