Application Number 53276

The City of Terre Haute is an equal opportunity employer. Applicants are considered for employment without regard to race,

color, religion, gender, age, national origin, status, physical or mental disability, gender identity, sexual orientation, or any

other basis prohibited by law, unless such basis constitutes a bona fide occupational qualification. The City of Terre Haute

will comply with its legal obligation to provide reasonable accommodation to qualified individuals with disabilities.

The required information will be denoted with an asterisk *

Your Information

Last Name*

First Name*

Middle Initial

Phone Number*

Application Date*

Email Address* ( Email will be used to send status updates. )

Address Information

Present Address

City

State

Zip Code

I have lived at the present address for over 1 year

Yes

No

Previous Address

City

State

Zip Code

Position

Position Applied For Please specify the current open position

On what date can you start?

Available to work:

Full Time	Part Time	Temporary
On-Call	Overtime	Any Shift

Why do you think you would make a valuable employee for the City of Terre Haute?

Why do you desire to make a change from your current employer?

Status

Are you legally authorized to work in the United States?*

Yes

No

Will you now or in the future require sponsorship for employment visa status (e.g. H-1B visa status)?*

Yes

No

Are you at least 18 years of age?*

Yes

No

You must obtain a work permit prior to employment.

Are you on layoff and subject to recall at another employer?

Yes

No

Have you filed an application here before?

Yes

No

Previous Application Date

Have you ever been employed here before?

Yes

No

Previous Employment Date

Do you have any friends or relative that work for the City?

Yes

No

List them by name and relationship.

Have you been convicted of a crime other than a minor traffic-related infraction that has not been expunged by a court? (A conviction or plea will not necessarily disqualify you from consideration for employment. The effect of a conviction will be assessed with respect to time, circumstances, seriousness of the offense, and job responsibilities and duties. However, your failure to list a conviction will disqualify you from consideration for employment or will result in your immediate termination of employment if subsequently discovered.)

Yes

No

If yes, state the nature of the conviction or plea, the date, and explain:

Education

High School

Name & City/St

Major

Graduate

Yes

No

Degree

College

Name & City/St

Major

Graduate

Yes

No

Degree

Graduate

Name & City/St

Major

Graduate

Yes

No

Degree

Employment History

1. Most Recent Employer

Name & Address Maximum of 85 characters.

Phone Number

Your Job Title & Duties Maximum of 120 characters.

Immediate Supervisor (name & title)

Hire Date

Date Left

Reason for Leaving Maximum of 350 characters.

Starting Rate

Ending Rate

2. Previous Employer

Name & Address Maximum of 85 characters.

Phone Number

Your Job Title & Duties Maximum of 120 characters.

Immediate Supervisor (name & title)

Hire Date

Date Left

Reason for Leaving Maximum of 350 characters.

Starting Rate

Ending Rate

3. Previous Employer

Name & Address Maximum of 85 characters.

Phone Number

Your Job Title & Duties Maximum of 120 characters.

Immediate Supervisor (name & title)

Hire Date

Date Left

Reason for Leaving Maximum of 350 characters.

Starting Rate

Ending Rate

May we contact the employers listed above?

Yes

No

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If no, please list specific employers you do not want us to contact and the reason you would prefer we did not.

Have you ever been discharged, permitted to resign rather than be discharged, or asked to resign from any positions?

Yes

No

If yes, please state the employer, and the reason for the discharge or resignation

Why?

Which of your previous jobs have you liked best?

Which of your previous jobs have you liked Least?

Why?

References Professional References (no relatives please)

Name

Occupation

Phone

Name

Occupation

Phone

Name

Occupation

Phone

Name

Occupation

Phone

Job Applicant’s Statement (Please indicate that you have read and understand each paragraph of the Applicant’s Statement by selecting I Agree or I Disagree beside each paragraph)

I certify that this application was completed by me and that all entries and information in it are TRUE and COMPLETE to the best of my knowledge. I understand that false, misleading or omitted information in my application may result in the rejection of my application, the revocation of an offer of employment, or discharge.*

I Agree

I Disagree

I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. I understand that an investigation may be made and information may be obtained through interviews with personal references and past employers, through a credit check, a criminal history check and/or a driver’s record check. This inquiry may include information as to, among other things, my character, general reputation and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references, former employers or others that are given in response to the inquiry. If the City of Terre Haute decides to obtain a consumer credit report, I understand the City of Terre Haute will provide, at my request, the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of information contained in such report.*

I Agree

I Disagree

I hereby release all parties, including but not limited to the City of Terre Haute, personal references and previous employers, from liability for any inquiry or damage that may result from their furnishing information concerning me or any action the City of Terre Haute take son the basis of such information.*

I Agree

I Disagree

I understand that, if I am offered a job, as a condition of my employment, I may be required to undergo a physical examination and drug screen, and I hereby authorize any doctor, hospital, clinic, laboratory and/or other medical facility to furnish any medical information with reference to me as may be necessary in conjunction with that examination and related considerations.*

I Agree

I Disagree

I understand that, according to federal law, all individuals who are hired must, as a condition of employment, produce certain documents to verify their identity and United States status, or if aliens, their legal authorization to work in the US. Employment is contingent upon my ability to produce the required documentation with the time period required by law.*

I Agree

I Disagree

I understand that this application is not, and is not intended not be, a contract of employment and that any resulting employment is for no fixed period of time and is terminable at any time for any reason by me or the City of Terre Haute. I understand that no representative of the City of Terre Haute, other than an officer, has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing and that any such agreement must be in writing to be valid.*

I Agree

I Disagree

I certify that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that might be offered by the City of Terre Haute.*

I Agree

I Disagree

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Signature *

AN EQUAL OPPORTUNITY EMPLOYER

Electronically Signed

Kristy Seliger

X

HR Director

City of Terre Haute

17 Harding Ave

Terre Haute

IN

812-244-2500

Kristy

Seliger

47805

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