Job Application

* indicates required field

*Last Name: *Last Name:

*First Name: *First Name:

*M.I.: *M.I.:

*Date: *Date

*Street Address: *Street Address:

Apartment/Unit #: Apartment/Unit #:

*City: *City:

*State:

*ZIP: *ZIP:

*Phone: *Phone

*Email Address: *Email Address

*Date Available: *Date Available

*Desired Salary: *Desired Salary:

*Position Applied For: *Position Applied For:

*Type of Employment Desired:

*Referral Source:

*Do you have any relatives working for Fairfield Township? *Do you have any relatives working for Fairfield Township?: Yes No

If so, who?: If so, who?:

*Have you worked for Fairfield Township before? *Have you worked for Fairfield Township before?: Yes No

If so, when?: If so, when?:

*Do you currently have a CDL? *Do you currently have a CDL?: Yes No

*Are you a citizen of the United States? *Are you a citizen of the United States?: Yes No

If no, are you authorized to work in the U.S?:

Employment History

Provide the following information from your past and current employers, assignments, or volunteer activities, starting with your most recent. Explain any gaps in employment in the comments section below.

Job #1

Employer: Employer:

Phone: Phone

Address: Address:

Supervisor: Supervisor:

Job Title: Job Title:

Starting Salary: Starting Salary:

Ending Salary: Ending Salary:

Responsibilities : Responsibilities :

From: From

To: To

Reason for Leaving: Reason for Leaving

May we contact your supervisor for reference?:

Job #2

Employer: Employer:

Phone: Phone

Address: Address:

Supervisor: Supervisor:

Job Title: Job Title:

Starting Salary: Starting Salary:

Ending Salary: Ending Salary:

Responsibilities : Responsibilities :

From: From

To: To

Reason for Leaving: Reason for Leaving

May we contact your supervisor for reference?:

Job #3

Employer: Employer:

Phone: Phone

Address: Address:

Supervisor: Supervisor:

Job Title: Job Title:

Starting Salary: Starting Salary:

Ending Salary: Ending Salary:

Responsibilities : Responsibilities :

From: From

To: To

Reason for Leaving: Reason for Leaving

May we contact your supervisor for reference?:

Additional Information

Comments (including explanation of any gaps in employment): Comments (including explanation of any gaps in employment)

Skills, Qualifications & Certifications: Skills, Qualifications & Certifications

Education

High School

*High School: *High School:

*Address: *Address:

*From: *From

*To: *To

*Did You Graduate?:

*Degree: *Degree:

College

College: College:

Address: Address:

From: From

To: To

Did You Graduate?:

Degree: Degree:

Other

Other: Other:

Address: Address:

From: From

To: To

Did You Graduate?:

Degree: Degree:

References

(Please list three professional references that are not related to you and are not previous supervisors. If not applicable, list three personal references not related to you.)

Reference #1

*Full Name: *Full Name:

*Relationship: *Relationship:

*Company: *Company:

*Phone: *Phone

*Address: *Address:

Reference #2

*Full Name: *Full Name:

*Relationship: *Relationship:

*Company: *Company:

*Phone: *Phone

*Address: *Address:

Reference #3

*Full Name: *Full Name:

*Relationship: *Relationship:

*Company: *Company:

*Phone: *Phone

*Address: *Address:

Additional Information: Organizations

List professional, trade, business, or civic associations and any offices held. Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability, or any other similarly protected status.

Organization: Organization:

Office Held: Office Held:

Organization: Organization:

Office Held: Office Held:

Organization: Organization:

Office Held: Office Held:

Organization: Organization:

Office Held: Office Held:

Additional Information: Awards

List special accomplishments, publications, awards, etc. Exclude information which would reveal sex, race, religion, origin, age, color, disability, or any other similarly protected status.

Awards: Awards

Additional Information: Other

List any other information that you would like us to consider. Exclude information which would reveal sex, race, religion, origin, age, color, disability, or any other similarly protected status.

Additional Information: Additional Information

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I understand that if I meet all requirements and characteristics as indicated in the job description, hiring may be contingent upon successful completion of drug and alcohol test, a credit report, and medical examination.

These costs will be borne by the Township.

I understand that if employed:

I may be required to work additional or fewer hours at other than my current assignment as the needs of the Township require.

My employment is subject to complying with those rules, regulations, and conditions as established by management.

I will be required to conform to all existing and future policies and procedure of Fairfield Township.

Fairfield Township reserves the right to change wages, hours, and working conditions, as deemed necessary.

I understand that if I am offered employment that I must provide appropriate documentation of my eligibility to work in the United States, in compliance with Immigration Reform and Control Act.

I also understand that if I fail to provide the documentation required by law prior to my first day of employment, I will not be allowed to begin work, and the offer of employment may be rescinded.

I understand that no employee is authorized to offer me employment, promise me salary increases, change of position, advancement, or any other advantages except those officially announced by the Fairfield Township Board of Trustees.

*Signature: *Signature:

*Date: *Date

Equal Opportunity Statement

Fairfield Township provides equal opportunities (EEO) to all employees and applicants for employment.

Without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance

with applicable federal, state, and local laws.

Fairfield Township complies with applicable state and local laws governing non-discrimination employment in every location in which the Township has facilities.

This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Fairfield Township expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status.

Improper interference with the ability of Fairfield Township employees to perform their expected job duties is absolutely not tolerated.