APPLICATION FOR EMPLOYMENT

City of Clear Lake

P.O. Box 107

125 Third Avenue South

Clear Lake, SD 57226-0107

Answer all questions-please print!!

In compliance with Federal and State employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a disability or handicap.

Date of Application

Position(s) Applied For

Referral Source F Advertisement F Friend F Relative

F Employment Agency F Other

Name Social Security No.

Last First Middle

Present Address Phone No.

Street City State Zip

Have you filed an application or been employed here before? F Yes F No

Are you a citizen of the United States? F Yes F No

If not, do you possess an Alien Registration Card? F Yes F No

Have you been convicted of a felony or released

from prison within the last 7 years? F Yes F No

If yes, describe in full, including date(s)

Would you work: F Full-Time F Part-Time

Specify days/hours if part-time

If your job requires you to travel, do you have a valid driver’s license? F Yes F No

Give the name, address, and phone number of three (3) references not related to you or a former employee.

1.

2.

3.

EMPLOYMENT EXPERIENCE

List each job held. Start with your present or last job. Include military service assignments & volunteer activities

Employer	Dates		Work Performed
	From	To
Address
Job Title	Hourly Rate or Salary
	Starting	Final
Reason for Leaving

Employer	Dates		Work Performed
	From	To
Address
Job Title	Hourly Rate or Salary
	Starting	Final
Reason for Leaving

Employer	Dates		Work Performed
	From	To
Address
Job Title	Hourly Rate or Salary
	Starting	Final
Reason for Leaving

Employer	Dates		Work Performed
	From	To
Address
Job Title	Hourly Rate or Salary
	Starting	Final
Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with our organization?

EDUCATION

	Elementary	High School	College/University	Graduate/Professional
School Name
Years Completed (Circle)	4 5 6 7 8	9 10 11 12	1 2 3 4	1 2 3 4
Diploma/Degree
Describe Course of Study:
Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities:

AGREEMENT

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

I authorize you to make such investigations and inquiries of my persona, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

Signature of Applicant Date

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview F Yes F No Date

Remarks

Employed F Yes F No Date of Employment

Job Title Hourly Rate/Salary Department