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Application for Employment

Position Desired
Date
Date available
Full Time Part Time

If part time, specify days and hours per week available

Personal Data

Name
	(Last, First, Middle)
Social Security Number
Street
City		State	Zip

Is any additional information relative to your name necessary to enable a check on your work record? If yes explain.

Phone number(s) where you can be reached
Are you at least 21 years of age?	Yes No
If no, state date of birth
Are you a U.S. Citizen?	Yes No
If no, are you authorized to work in the U.S.?

Education and Training
High School
Name
Address
Did you Graduate?
Degree
Major Studies
Business or Trade School
Name
Address
Did you Graduate?
Degree
Major Studies
College
Name
Address
Did you Graduate?
Degree
Major Studies
Other (Specify)
Name
Address
Did you Graduate?
Degree
Major Studies
Special qualifications: (include technical and professional licenses, academic and professional awards, etc.

Computer Skills

List any programs you are familiar with and your current level of knowledge:

Employment Record (List all present and past employment with most recent first)
Employer's name
From
To
Address
Type of business
Phone
Starting Salary
Ending Salary
Name and title of supervisor
Your job title
Reason for leaving
Briefly describe the nature and duties of your position

May we contact your present employer?

Employer's name
From
To
Address
Type of business
Phone
Starting Salary
Ending Salary
Name and title of supervisor
Your job title
Reason for leaving
Briefly describe the nature and duties of your position


Employer's name
From
To
Address
Type of business
Phone
Starting Salary
Ending Salary
Name and title of supervisor
Your job title
Reason for leaving
Briefly describe the nature and duties of your position


Employer's name
From
To
Address
Type of business
Phone
Starting Salary
Ending Salary
Name and title of supervisor
Your job title
Reason for leaving
Briefly describe the nature and duties of your position


Employer's name
From
To
Address
Type of business
Phone
Starting Salary
Ending Salary
Name and title of supervisor
Your job title
Reason for leaving
Briefly describe the nature and duties of your position

Unemployment Record
(Account for periods of unemployment of one month duration or more in the past 5 years)
Reason for Unemployment
From
Month Year
To
Month Year

Reason for Unemployment
From
Month Year
To
Month Year

Reason for Unemployment
From
Month Year
To
Month Year

Reason for Unemployment
From
Month Year
To
Month Year

Reason for Unemployment
From
Month Year
To
Month Year

Have you ever been dismissed or asked to resign from any position?	Yes No
If yes, give details in space provided below

Have you ever been convicted of a crime in a court of law?	Yes No
If yes, give details below in space provided (excluding minor traffic vio lations). Criminal record will not necessarily exclude you from employment.

If employed, what length of time do you expect to reside in this area?

Military Experience (if applicable)
Describe any job-related training received in the United States military.

Are you requesting consideration of Veteran's Status?	Yes No
(Note: per decision of Pennsylvania's Supreme Court, preference for veterans is limited to entry level employment.)

If you are, provide the following information:
Date of Discharge:
Type of Discharge:
(Verification of Veteran's status may be required.)

References
(Do not list relatives, only persons who can provide employment, education, or character references)

Name
Address
Occupation
Phone (Home)
(Office)

Name
Address
Occupation
Phone (Home)
(Office)

Name
Address
Occupation
Phone (Home)
(Office)

Use this space to describe your interest in the position, to summarize any additional information necessary to describe you full qualifications, and to explain answers to previous questions as noted on previous pages.

Public Works Department Applicants Only
Do you have a Pennsylvania commercial driver's license?	Yes No
Have you had any past experience in driving a truck?	Yes No
If yes, state experience and type of truck.

Have you had any past experience in driving heavy equipment or operating heavy equipment?	Yes No
If yes, state experience and type of truck.

Are you willing to work odd hours, for example 2 a.m. to 10 a.m.?	Yes No
Will you be available at any hour for emergency work?	Yes No
Can you be conveniently reached by telephone?	Yes No
Do you have a reliable means of transportation to place of employment regardless of the time of day?	Yes No
How many miles do you live from Ebensburg?	Yes No
Do you understand that this job requires outside work in all kinds of weather, such as rain, snow, sleet as well as hot and cold weather?	Yes No
Are you willing to perform all types of physical labor including pick and shovel work, sewer cleaning, snow removal, etc.?	Yes No

Signature
I understand that this employment application shall be considered valid for a period of time not to exceed (90) days. If I still desire a position with Ebensburg Borough after this employment application expires, it will be my duty to complete a new employment application and file it with the Borough. The facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that, if employed, false statements on this application shall be sufficient cause for dismissal. I also understand that to qualify for employment, I may be subject to a background investigation and a medical examination.

Signed		Date

Resumé:

Ebensburg Borough does not discriminate on the basis of race, color, religion, national origin, sex, age or disability as defined by law.

Application for Employment

Personal Data