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Personal Information

First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Phone Number*
Email Address*
Have you ever been convicted of a violation of the law other than a minor traffic violation in the past 7 years?*
1. Yes
1. No
Conviction Explanation
If yes, please explain above. Such convictions may be relevant if job related, but does not necessarily bar you from employment
Are you eligible to work in the United States?*
1. Yes
1. No
Certain certifications, permits, or licenses may be required. Select all that you currently possess. If you are hired, you must possess the required certifications that are listed in the job description. You will be required to furnish a copy.
1. Food Handler's Permit
2. Current Negative TB Test
3. First Aid
4. Child CPR
5. Adult CPR
6. Lifeguard
7. CPR/AED for the Professional Rescuer
8. Bloodborne Pathogens
9. Driver's License
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(From Most Recent)
Company
Position
Address
Phone Number
Supervisor
Employed From - To (Dates)
Responsibilities
Reason for Leaving
Provide a reason for leaving the employer.
May we contact your previous supervisor for a reference?
1. Yes
1. No
Company
Position
Address
Phone Number
Supervisor
Employed From - To (Dates)
Responsibilities
Reason for Leaving
Provide a reason for leaving the employer.
May we contact your previous supervisor for a reference?
1. Yes
1. No
Company
Position
Address
Phone Number
Supervisor
Employed From - To (Dates)
Responsibilities
Reason for Leaving
Provide a reason for leaving the employer.
May we contact your previous supervisor for a reference?
1. Yes
1. No
Comments
Please explain any gaps in employment or other information you would like to share regarding your employment history.
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Please list two business/work references who are not related to you and are not previous supervisors. If you don't have any business or work references, list two school or personal references who are not related to you.
Full Name*
Relationship*
Company*
Phone Number*
Full Name*
Relationship*
Company*
Phone Number*
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I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment.

I understand that the company may require me to successfully complete a pre-employment drug and alcohol test and a background check as a condition of employment and that continued employment may be based on the successful completion of similar tests.

Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.
Applicant Signature*
Date
Date
EEO Statement
The City of Cheney is a drug-free, Equal Opportunity Employer and does not unlawfully discriminate on the basis of race, sex, age, color, sexual orientation, religion, national origin, marital status, genetic information, veteran’s status, disability, or any other basis prohibited by federal, state, or local law.

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