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Educational Background

Indicate last year completed:

Degree Program

Degree acquired?

Yes No

Name and Location of last school attended:

Employment History

Provide the following information on your past and current employers for the last 10 years starting with the most recent employer. Explain any gaps in employment in the comments section.

Employer Name

Address

Phone

Title:

Description of Duties

Name and Title of previous supervisor:

May we contact this employer?

Yes No

Dates employed:

Ending Salary:

Reason for leaving?

Employer Name

Address

Phone

Title:

Description of Duties

Name and Title of previous supervisor:

May we contact this employer?

Yes No

Dates employed:

Ending Salary:

Reason for leaving?

Employer Name

Address

Phone

Title:

Description of Duties

Name and Title of previous supervisor:

May we contact this employer?

Yes No

Dates employed:

Ending Salary:

Reason for leaving?

Employer Name

Address

Phone

Title:

Description of Duties

Name and Title of previous supervisor:

May we contact this employer?

Yes No

Dates employed:

Ending Salary:

Reason for leaving?

Additional Skills and Qualifications

Summarize any skills, qualifications, awards or training not listed elsewhere in this application.

Reading Comprehension and Writing Skill Level

Rate your level of ability with the following computer applications:

MS Word

MS Excel

MS Access

Email Applications

Clerical Applicants:

Typing Speed (WPM)

10-Key

Sight Touch

Comments

State any additional information you feel may be helpful in considering your application.

References

List name and telephone number of three business/work references who are not related to you.

Name

Phone Number

Title

Years Known

Name

Phone Number

Title

Years Known

Name

Phone Number

Title

Years Known

Previous Addresses

List all addresses other than the address at the beginning of the form for the past 10 years.

Address

City, State, Zip

Address

City, State, Zip

Address

City, State, Zip

Address

City, State, Zip

Driver's License Information

Answer the questions in this section ONLY if applying for a position that requires operation of Town of Berlin Vehicles. Must be accompanied by 3 year MVA driving record.

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

Has any license, permit or privilege ever been suspended or revoked?

Yes No

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes No

if you answered yes to any pof the above, give details including state, violations, penalties, etc.:

Affirmative Action Voluntary Information

Completion of the information below is voluntary. We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

Please choose one of the following Equal Employment Opportunity Identification Groups:

Please Read the Following Statement Before Signing

Polygraph: "Under the law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit or to take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor, and subject to a fine not to exceed $100."

Note: For electronic submission: In lieu of signature, electronic signature or typed initials will be accepted.

Applicant Signature*

I hereby certify that the information I have given on my application is, to the best of my knowledge, information and belief, true and correct. Applications may be disqualified prior to 1 year for reasons including but not limited to, failure to appear for interview, poor references or misrepresentation or omission of facts. Misrepresentation or omission of facts on my application, whenever discovered, may result in termination of employment. I hereby authorize the Town of Berlin, or its representatives, to inquire of each of my former employers, references and all other persons having information concerning me, to disclose my full employment record and any other information they may have concerning me including results of controlled substance test results. I hereby release and hold harmless from any and all liability in connection with requesting such information The Town of Berlin, its representatives, agents and employees. I further release from any liability, any third parties furnishing such information upon request by the Town of Berlin.

I understand this application and any other Town documents are not contracts of employment, and that any individual who is hired may voluntarily leave upon notice, and may be terminated by the Town at any time and for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee or contractor. I also understand that I will be subject to a probationary period should I become employed by The Town of Berlin.

Note: For electronic submission: In lieu of signature, electronic signature or typed initials will be accepted.

Applicant Signature*

Employment/Human Resources

Personal Information

Educational Background

Employment History

Additional Skills and Qualifications

Comments

References

Previous Addresses

Driver's License Information

Affirmative Action Voluntary Information

Please Read the Following Statement Before Signing