City of Ely

An Equal Opportunity Employer

PO Box 248

1570 Rowley Street

Ely, IA 52227

Phone/Fax:(319) 848-4103

Email: elycity@southslope.net

EMPLOYMENT APPLICATION

Date: Position applied for:

Note: it is to your advantage to answer all questions on this application. (Please print neatly or type.)

Name:

Last First Middle Initial

Social Security Number: Telephone Number:

Cell phone (optional): email:

Address:

Street City State Zip

To facilitate reference checks, please indicate any other name under which you have been employed:

Have you worked for the City of Ely before? YES NO (circle one)

If yes, please complete the following information: Date:

from to

Position(s) held: Department:

Reason for leaving:

Do you have any relatives who work with the City of Ely? YES NO (circle one)

Name(s) & Relationship:

Have you been given a copy of the job description or had the requirements of the job explained to you? YES NO

Do you understand the requirements of the job? YES NO

Can you perform the requirements of this job with or without a reasonable accommodation? YES NO

If the job requires, do you have the appropriate valid driver’s license? YES NO

Type State Expiration date

Are you a United States Military Veteran? YES NO (circle one) Branch of Service:

Dates of Military Service:

from to

Those wishing to claim Veteran’s preference must submit Proof of Service Form DD214 at time of interview.

EDUCATION

Circle highest grade completed: 6 7 8 9 10 11 12 GED College: 1 2 3 4 5 6 7 +

Institution Course of Study Degree Attained

High School Diploma/GED

Location of School

College Attended

Location of College

College Attended

Location of College

List any additional training – work shops, volunteer work, etc., you have received that makes you more qualified for this position.

Which of the required skills in the job announcement do you possess?

What equipment can you operate?

Do you have any other experience or qualifications not already listed that relate to the job applied for?

Have you ever been convicted of a felony? (For the purpose of this question “convicted” includes found guilty, plead guilty, plead no contest or been given a deferred sentence or judgment) YES NO

If Yes please explain, please include the facts of your case, the felony you were convicted for and how long ago.

(Note: A conviction will not automatically disqualify an applicant for a job. The type and seriousness of the crime, the frequency of violations, the date of convictions, and the applicant’s entire work and educational history will all be considered.)

EMPLOYMENT HISTORY

Start with your present or last job and include at least your last five years of work records. Please fill out this section carefully and completely, as you are only given credit for jobs you list and the dates you include. Please attach an additional sheet if you need more space. Include military experience and describe any major duty assignments. Include periods of self-employment. Give details of supervisory positions you may have had.

If you are currently employed, may we contact your present employer? YES NO (circle one)

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

Employed by: Telephone Number:

Address: Supervisor’s Name:

Job Title: Duties:

Employed from: (mo/year) To: (mo/year)

Starting Salary: Final Salary: Hours per week:

Reason for leaving:

What date would you be available to begin work?

NOTE: All applicants will be required to pass a pre-employment drug and alcohol screen and physical evaluation after being offered a position and beginning as an employee of the City of Ely.

I attest that all statements on this application are true and correct. I understand that intentionally false statements made on this application will eliminate me from further consideration for employment or will be grounds for dismissal. I authorize the City of Ely and my previous employers (with the exception of ) to conduct or participate in an investigation of my personal background, work history and police record as may be necessary to verify the information provided in my employment application and to determine my fitness to hold the position for which I have applied.

Applicant Signature Date

FOR PERSONNEL DEPARMENT USE ONLY

Reviewed by: Position considered for / Referral to: