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2. 
3. Date
5. Department You Are Applying For
   -- Select One --Public WorksStreet Division
6. Job Your Applying For
   -- Select One --Residential Building InspectorStreet Maintenance Tech 1Solid Waste Attendant 1
8. First Name
9. Middle Name
10. Last Name
12. Mailing Address
14. City
15. State
16. Zip Code
18. Phone
19. Cell / Other Phone
21. Email Address
25. States*
27. City of Birth
28. County of Birth
32. State*
33. Country (if not the United States)
37. Do you have a valid drivers license?*

    1. Yes
    2. No
39. Do you have a valid Class B CDL?*

    1. Yes
    2. No
41. Have you been convicted of a felony with the last 7 years?*

    1. Yes
    2. No
43. If yes, please explain
45. Have you ever filed an application with us before?*

    1. Yes
    2. No
47. Please gives dates*
49. Have you ever been employed by us before?*

    1. Yes
    2. No
51. Please list dates of employment*
53. Do you have any relatives working for us?*

    1. Yes
    2. No
55. Please list names*
59. High School Name
61. Mailing Address
63. City
64. State
65. Zip Code
67. From Date Attended High School
68. To Date Attended High School
70. Years Completed
71. Did you graduate?

    1. Yes
    2. No
75. College University Name
77. Mailing Address
79. City
80. State
81. Zip Code
83. From Date Attended College
84. To Date Attended College
86. Did you graduate?

    1. Yes
    2. No
87. Type of Degree
91. Other Schools (Trade, Vocational, Business, Police Academies or Military)
93. Mailing Address
95. City
96. State
97. Zip Code
99. From Date Attended School
100. To Date Attended School
102. Area of Study
103. Did you graduate?

     1. Yes
     2. No
105. Type of Degree of Certificate
109. Computer Skills

     1. Word
     2. Excel
     3. Outlook
     4. PowerPoint
     5. Other
110. Other
112. General Computer Knowledge

     1. Basic
     2. Advanced
113. State approximate number of words per minute: Typing
115. Do you speak, read, or write any foreign languages?

     1. Yes
     2. No
117. What foreign languages do you know?
119. On what date are you available to work?

123. Please enter the details of your last 3 employers.

125. Company / Name*
126. Phone
128. Mailing Address
130. City
131. State
132. Zip Code
134. Your Position
136. Duties
138. Date Employment Started
140. Date Employment Ended
142. Reason for Leaving
144. Starting Salary
146. Ending Salary
148. Supervisor Name
150. Supervisor Title
152. May we contact the Supervisor?

     1. Yes
     2. No
154. Company / Name*
155. Phone
157. Mailing Address
159. City
160. State
161. Zip Code
163. Your Position
165. Duties
167. Date Employment Started
169. Date Employment Ended
171. Reason for Leaving
173. Starting Salary
175. Ending Salary
177. Supervisor Name
179. Supervisor Title
181. May we contact the Supervisor?

     1. Yes
     2. No
183. Company / Name*
184. Phone
186. Mailing Address
188. City
189. State
190. Zip Code
192. Your Position
194. Duties
196. Date Employment Started
198. Date Employment Ended
200. Reason for Leaving
202. Starting Salary
204. Ending Salary
206. Supervisor Name
208. Supervisor Title
210. May we contact the Supervisor?

     1. Yes
     2. No
212. References
214. Name of Reference
215. Phone
217. Name of Reference
218. Phone
220. Name of Reference
221. Phone

223. The Public Works Department is an Equal Employment Opportunity/ Affirmative Action Employer. We consider applicants for all positions without regard to race, color, natural origin, sex, age, handicap, marital status, religion, or any other legally protected status.

     I understand that my appointment or employment will be contingent upon the results of a completed background investigation. I am aware that any omission, falsification, misstatement or misrepresentation will be the basis for my disqualification as an applicant or my dismissal from the Carthage Public Works Department. I agree to the conditions and certify that all statements made by me on this application are true, correct and complete, to the best of my knowledge. I understand that this employment application shall become the property of the Carthage Public Works Department.

     I further understand and agree that my employment or appointment will be contingent upon the results of a complete drug test and that I may be required to take drug test during the term of my employment or appointment with the Carthage Public Works Department.

     I understand that the use of drugs and alcohol is not permitted, during work or duty time, whether paid or unpaid, in the areas, including vehicles, where work is performed by employees or appointees.

     I further authorize the Carthage Public Works Department or an agent of the Carthage Public Works Department, without need of further authorization, to obtain medical records allowed by law if I claim rights to payment or receipt of any benefit pursuant to state or federal law.

     I further agree to give any authorization as may be required by the Health Insurance Portability Accountability Act of 1996 (HIPAA) for health care providers to release the necessary medical information to process my application for employment.

     I understand and agree that any employment or appointment offered to me will be contingent upon my acceptance of compensatory time off, instead of cash, in payment for overtime hours that I work, to the extent allowed by law. I understand, however, that the Carthage Public Works Department has the absolute discretion to periodically substitute cash, in whole or part, for my accrued compensatory time.

     I authorize any of the persons or organizations referenced in this application to furnish information, personal or otherwise, regarding my ability and fitness for employment or appointment with the Carthage Public Works Department and I release all such parties from any and all liability for any damage that might result from furnishing such information to the Carthage Public.

     I agree to conform to the rules, regulations, and orders of the Carthage Public Works Department and acknowledge that these rules, regulations, and orders may be changed, interpreted, withdrawn, or added to by the Carthage Public Works Department, as its discretion, at any time and without any prior notice to me.

225. You must agree to the disclosure statement provided in order for us to accept your application.*

     1. Yes I Agree
Leave This Blank:


227. 1. Receive an email copy of this form.
228. Email address

     This field is not part of the form submission.

229. Submit

* indicates a required field