POSITION APPLIED FOR

GENERAL INFORMATION

^{Name (last, first, middle initial)                                                                                                                              Social Security No. (Optional)}

^{Street Address                                                                                                                                                                       City, State, Zip}

^{Home Phone No.                                                                                                  Work Phone No.                                                                                       Message Phone No.}

^{Are you authorized to work in the United States?   Proof of Authorization will be required post hire.}

^{Yes   No}                                          

TRAINING AND EDUCATION

Circle highest grade completed:           8                  9                  10             11               12             GED

^{Colleges/other training}

^{Major/subject}

^{Degree/certificates}

ADDITIONAL SKILLS  Describe skills relevant to the job for which you are applying

SKILL

TYPE OF EXPERIENCE

LEVEL OF EXPERTISE

Office equipment, computers, software (typing speed, programs, etc.)

Technical skills, professional licenses

Heavy equipment, machinery

Other

Can you perform the essential functions of the job with or without reasonable accommodation?      Yes                No  

BACKGROUND INFORMATION

each case is considered separately based on job duties and performance areas

Do you have a valid Tennessee State Driver's License?                   Yes              No                 Other State _____________

(If position applied for involves driving), have you been convicted, pleaded to no contention or paid a fine for any traffic violations in the past three (3) years?                         Yes              No           If yes please explain:

Have you been convicted of a felony or served time in prison within the last ten (10) years?    Yes             No

Conviction will not necessarily bar you from employment.  If yes, please explain:

How/where did you hear about the position for which you are applying?  (Check one)

______ Friend or relative

______ City employee

______ Employment Security

______ Newspaper ad

Which?__________________________

______ City job bulletin

______ City job hotline

______ Other please specify  ______________________________

EMPLOYMENT HISTORY

Beginning with your present or most recent employment, list your employment history.  Include self-employment, military service, volunteer experience and periods of unemployment.  The following sections MUST be completed even if a resume is submitted.

Employer

Employed from:

To:

Address:

Supervisor

Phone

Hours worked/week

Starting salary

Position

Last salary

_{Primary duties}

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

Reason for leaving

Employer

Employed from:

To:

Address:

Supervisor

Phone

Hours worked/week

Starting salary

Position

Last salary

_{Primary duties}

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

Reason for leaving

Employer

Employed from:

To:

Address:

Supervisor

Phone

Hours worked/week

Starting salary

Position

Last salary

_{Primary duties}

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

Reason for leaving

Employer

Employed from:

To:

Address:

Supervisor

Phone

Hours worked/week

Starting salary

Position

Last salary

_{Primary duties}

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

Reason for leaving

PROFESSIONAL REFERENCES

Please list below any people in addition to supervisors listed above who can responsibly evaluate your work performance

Name

Place of employment/title

Phone