Village Of Riverdale
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Report A Concern
Application for Employment
Step
1
of
9
11%
Applicant Information
Name
First
Middle
Last
Date
MM slash DD slash YYYY
Address
Street Address & Apartment/Unit#
City
State
Zip Code
Home Phone
Cell Phone
Email
Are you over the age of 18?
Yes
No
Are you a citizen of the United States
Yes
No
Are you legally eligible for employment in the United?
Yes
No
(If offered employment, you will be required to provide documentation to verify eligibility)
Social Security No:
Date of Birth:
MM slash DD slash YYYY
Date Available:
Desired Salary:
Position (s) Applied for:
Have you ever been employed by the Village of Riverdale?
Yes
No
If yes, when?
Referred by:
Ad
Friend
Relative
Agency
Other
Do you have a valid Driver’s License?
Yes
No
If yes, please provide number
Have you ever been convicted of a felony?
Yes
No
If yes, explain:
Education
High School:
Address:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Did you graduate?
Yes
No
Diploma
College/University:
Address:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate?
Yes
No
Degree:
Other:
Address:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Did you graduate?
Yes
No
Degree:
Professional Licenses, Certifications or Membership
Type:
Expiration Date:
MM slash DD slash YYYY
Professional Membership:
*You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status*
Military Service
Branch:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Special Skills
Summarize any special skills or qualifications that you acquired through employment or other experience that are applicable to the job that you are applying for:
Personal Data
May we contact your current employer?
Yes
No
Some positions require that you work shifts, weekends, or other hours outside the “normal” work day. Are you willing to work weekends, holidays or hours outside the normal work day?
Do you have any friends or family who currently work for the Village of Riverdale?
Yes
No
If so, provide their names:
References:
Please add references below. (Note: Two of the References must be Professional References)
Reference 01
Full Name:
Relationship:
Company:
Phone:
Address:
Reference 02
Full Name:
Relationship:
Company:
Phone:
Address:
Reference 03
Full Name:
Relationship:
Company:
Phone:
Address:
Previous Employment
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Reason For Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Untitled
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary
Responsibilities:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Important! Please Read The Following Carefully
Certificate of Applicant
I hereby authorize a comprehensive investigation into my background, including but not limited to all statements contained in this application and any other document or documents submitted in conjunction with this application. I permit the Village of Riverdale to obtain any records, information and documents pertaining to my background and work experience. I also authorize previous individuals to disclose information about me on the subjects covered by this application form or related documents to this request. Any individual, educational institution, organization, or business providing such information. I also agree to release the Village of Riverdale from any and all liability arising from the use of the information obtained through the investigation of my background and any action taken by the Village of Riverdale based on such information. I understand that my employment is contingent upon the completeness and accuracy of the information on this application and upon satisfactory completion of a medical examination, which will include a drug test. I also understand that, if hired, I will be required to abide by the rules, policies, and procedures of the Village of Riverdale. Except as required by law, the Village’s rules, policies, and procedures relating to conditions of employment are subject to modification by the Village without notice. I understand that the Village is in no way obligated to provide me employment and that I am in no way obligated to accept employment with the Village. This application does not bind either party for a specific period of time regarding employment, and the statements contained herein do not constitute any form of a contract of employment. I understand that except for the Village Administrator or his/her agent, no representative of the Village has any authority to enter into any agreement contrary to the forgoing. I certify that all answers and statements contained in this application are true to the best of my knowledge and belief. False statements, omissions, or misrepresentations made in any phase of the hiring process, including but not limited to, the completion of any employment application, shall be grounds for excluding an applicant from any examination, or for omission or removal from an eligible register, or for dismissal from the Village of Riverdale after certification or hiring.
EEOC POLICY
The Village of Riverdale will provide equal opportunity to all employees and applicants for employment regardless of race, color, religion, age, sex, pregnancy, national origin, ancestry, disability (mental or physical), genetic information, military status, marital status, order of protection status, transgendered status, sexual orientation all in accordance with applicable law. Such action shall include, but is not limited to: initial consideration for employment; job placement and assignment of responsibilities; performance evaluation; promotion and advancement; compensation and fringe benefits; training and professional development opportunities; formulation and application of human resource policies and rules; facility and service and accessibility; and discipline and termination.
EEOC POLICY
The Village of Riverdale will provide equal opportunity to all employees and applicants for employment regardless of race, color, religion, age, sex, pregnancy, national origin, ancestry, disability (mental or physical), genetic information, military status, marital status, order of protection status, transgendered status, sexual orientation all in accordance with applicable law. Such action shall include, but is not limited to: initial consideration for employment; job placement and assignment of responsibilities; performance evaluation; promotion and advancement; compensation and fringe benefits; training and professional development opportunities; formulation and application of human resource policies and rules; facility and service and accessibility; and discipline and termination.
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.
Signature of Applicant
Max. file size: 10 MB.
Date:
MM slash DD slash YYYY
Print Full Name
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