City of LaGrange

First Name

Last Name

Middle Name:

Yrs @ Address:

Major fields of employment interest and positions desired.:

Former city employee?
 Yes  No

Dept./Division:

Job Title & Duties:

Employed Dates:
to

Have you ever been convicted from violating any law? (A yes will not necessarily disqualify you for employment consideration.)  Yes  No

If yes, please explain.

In case of an emergency notify:
Name:

Address:

Phone No.:
( )

High School:

Located:

Dates Attended:

to

Last grade completed, diploma, or degree:

Course of study:

College:

Located:

Dates Attended:

to

Last grade completed, diploma, or degree:

Course of study:

Use this space for comments about your special abilities. ie. Apprenticeships, tools, certifications, experience, etc.:

Job 2 - Contact this employer.

Name of Employer:

Address:

Phone:
( )

Dates
Employed:
to

Wage Rate
Start/Finish:

Job Title/Duties:

Reason for Leaving:

Supervisor's Name:

Job 4 - Contact this employer.

Name of Employer:

Address:

Phone:
( )

Dates
Employed:
to

Wage Rate
Start/Finish:

Job Title/Duties:

Reason for Leaving:

Supervisor's Name:

Give work references that we may contact. (Include at least two most recent or current supervisors)

Reference 2

Name:

Address:

Occupation:

Phone:
( )

Reference 3

Name:

Address:

Occupation:

Phone:
( )

I have applied for employment with the City of LaGrange and hereby authorize the City of LaGrange to contact my current and former employers and references for the purpose of acquiring information regarding me; I hereby authorize such employers and references to supply such information verbally or in writing to the City of LaGrange. In consideration for their furnishing such information I hereby waive and all claims against such former employers and references which may arise from their furnishing such information.
    I understand the City of Lagrange has a Substance Abuse Prevention Program which includes drug testing. I agree to comply with applicable City policy.
    I understand that once offered a position I will be required to take a medical examination and drug screening.
    I understand that once offered a postion I may be required to pass a physical examination as a condition of continued employment.
    I certify that the answers given by me to all the questions on this application are to the best of my knowledge and belief, true and correct. I further affirm that I have not knowingly withheld any facts or circumstances that would detrimentally affect my application for employment, and I understand that any misleading or incorrect statement may render this application void and would be cause for dismissal, if employed.
    I AGREE THAT IF HIRED, THE CITY OF LAGRANGE OR I MAY TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE. I UNDERSTAND THAT NO CITY POLICY, PRACTICE, PROCEDURE, OR STATEMENT BY ANY CITY REPRESENTATIVE SHALL LIMIT OR ALTER THIS AT-WILL EMPLOYMENT RELATIONSHIP.
    I, the undersigned, am applying for a position of employment for the City of LaGrange. I understand that any appointment tendered to me will be contigent upon the results of a complete background investigation. I am aware that willfully withholding information or making false statements on my employment application will be the basis for refusal to hire me.
    I hereby release you, your organization, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages for whatever kind, which may result to me, my heirs, family, or associates because of compliance with this authorization and request to release information or any attempt to comply with it.
    I further understand that as a part of the processing of my application, I will be required to undergo a pre-employment screening, including, but not limited to, a criminal and/or driver history report. I hereby voluntarily sign this release form attesting to my understanding it and supporting the intent of same.