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FOR EMPLOYMENT APPLICATION CITY OF BROCKTON DEPARTMENT OF

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CITY OF BROCKTON
APPLICATION
FOR EMPLOYMENT
DEPARTMENT OF HUMAN RESOURCES
45 SCHOOL STREET
BROCKTON, MA 02301
(508)
580-7820
The City of Brockton, Section 2-110 of the Revised Ordinances of the City of Brockton mandates that at the time
of employment you must be a resident of the City of Brockton or shall, within one (1) year of employment establish
residency within the City.
INSTRUCTIONS: You must complete this application to be considered for employment. Along with the
submission of the required documents indicated on the job posting (if applicable).
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
Position
applying
for:
Today’s
Date:
Name:
Last
First
Middle
Zip Code
Cell
#:
Can you furnish proof you are eligible to work in the U.S.?
Yes No
Do
you
have
a
valid
driver’s
license?
Yes
No
Driver’s
License
#:
Do
you
have
a
valid
commercial
driver’s
license?
_Yes
No
Class
A
Class
B
Have you ever been employed with the City before? _ Yes No If yes, year(s)?: _
Reason
for
leaving:
EDUCATION: Please list high school, college, post grad and additional relevant training or studies.
School Name
Location
# of Years Attended
Degree Received
Major
MILITARY HISTORY:
Are you a veteran of the U.S. Armed Forces? Yes No
Branch:
_
Dates
of
Service:
From To
Rank
at
discharge:
_
Discharge
status:
Present
Military
status:_
City of
BROCKTON
Massachusetts
Mayor Moises M. Rodrigues
Use page 3 if more space is needed
Page 1
Address:
Number Street City/Town State
Years
Lived
at
Current
Address:
Home
Telephone
#:
E-Mail
Address:
Are you under the age of 18?
If yes, add D.O.B:
Last 4 Digits SS#: xxx-xx
Yes
No
Revised August 2019
EMPLOYMENT HISTORY: List names of employers with present employer listed first. Account for all periods of
time including military service and any periods of unemployment. If self-employed, please give firm name and
supply business references. Note: References will be contacted.
NAME OF EMPLOYER:
JOB TITLE AND DUTIES:
ADDRESS:
EMPLOYMENT DATES:
FROM: TO:_
CITY, STATE, ZIP CODE:
REASON FOR LEAVING:
TELEPHONE #:
IMMEDIATE SUPERVISOR:
NAME OF EMPLOYER:
JOB TITLE AND DUTIES:
ADDRESS:
EMPLOYMENT DATES:
FROM: TO:_
CITY, STATE, ZIP CODE:
REASON FOR LEAVING:
TELEPHONE #:
IMMEDIATE SUPERVISOR:
NAME OF EMPLOYER:
JOB TITLE AND DUTIES:
ADDRESS:
EMPLOYMENT DATES:
FROM TO:_
CITY, STATE, ZIP CODE:
REASON FOR LEAVING:
TELEPHONE #:
IMMEDIATE SUPERVISOR:
NAME OF EMPLOYER:
JOB TITLE AND DUTIES:
ADDRESS:
EMPLOYMENT DATES:
FROM: TO:
CITY, STATE, ZIP CODE:
REASON FOR LEAVING:
TELEPHONE #:
IMMEDIATE SUPERVISOR:
Can we contact your present and former employers? Yes No
If
no,
please
give
reason
why:
_
Have you worked under any other name? Yes No
If
yes,
give
names:
_
Page 2
Last Name:
First Name:
SPECIAL TRAINING & SKILLS:
What skills, special licenses or additional training do you have that are related to the job for which you are applying?
What
machines
or
equipment
can
you
operate
that
are
related
to
the
job
for
which
you
are
applying?
What
computer
programs
are
you
familiar
with?
ADDITIONAL COMMENTS & WORK EXPERIENCE SHEET:
Page 3
DO YOU CURRENTLY HAVE AN IMMEDIATE FAMILY MEMBER OR RELATIVE WORKING FOR THE CITY OF
BROCKTON OR THE COMMONWEALTH OF MASSACHUSETTS:
Name: Agency: Relationship:
Name: Agency: Relationship:
Name: Agency: Relationship:
No, I do not have any immediate family or relative(s) working for the City or the
Commonwealth of MA.
Yes, I do.
(Please list below)
_____________________________
_____________________________
____________________________
______________________________
______________________________
_____________________________
_________________________
_________________________
_________________________
Last Name:
First Name:
REFERENCES: Provide the names of three (3) responsible persons whom you have known well for a
long period of time. Do not submit names of relatives and one must be a professional reference.
Note: References in this section may be contacted.
Name:
Years
Known:
Address:
Number Street City/Town State Zip Code
Home
Telephone
#:
_ Cell
#:
_
Occupation:
Email
Address:
Name:
Years
Known:
Address:_
Number Street City/Town State Zip Code
Home
Telephone
#:
Cell
#:
Occupation:
Email
Address:
Name:
Address:
Home
Telephone
#:
Years
Known:
Cell
#:
Street
City/Town
State
Zip Code
Occupation:
Email Address:
AGREEEMENT
The City of Brockton does not discriminate in hiring or employment on the basis of age, sex, color, race, creed, national origin,
ancestry, veteran status, sexual orientation, religion, marital status, political belief, any other protected class or due to a disability
that does not prohibit performance of essential job functions. No question on this application is intended to secure information to
be used for such discrimination.
The information provided in this application for employment is true and complete. In the event of employment, I understand that
false or misleading information given in my application or interview(s) may result in discharge. Conditional offers of employment
are subject to passing a mandatory CORI (Criminal Offender Record Information) background check.
I understand that any employment offer by the City is conditional upon my ability to establish employment eligibility under the
Immigration Reform and Control Act of 1986. I authorize investigation of all statements contained in this application.
The City of Brockton is an Equal Opportunity/Affirmative Action Employer
Date:
Signature:
Number
Page 4
Last Name:
First Name:
CITY OF BROCKTON
VOLUNTARY SELF - IDENTIFICATION FORM
The City of Brockton has an Affirmative Action Program to ensure equal employment
opportunity. Applicants are considered for all positions without regard to race, color, national origin, sex or
age, marital status, veteran status, any other protected class or the presence of a non-job related medical
condition or handicap. We are asking you to help us measure the effectiveness of this program by answering
the questions below.
The information collected will be used for statistical purposes only. THIS FORM WILL NOT REMAIN
WITH YOUR APPLICATION, NOR WILL IT IN ANY WAY BAR YOU FROM
EMPLOYMENT CONSIDERATION. If you have any questions, comments, suggestions or complaints
about the employment process, please contact the Human Resources Department at (508) 580-7820.
Position Applied For: Date:
Sex:
q
Male
q
Female
Ethnic Origin (Please check the race you most strongly identify with):
NOTE: Ethnic origin is defined by the Federal Equal Employment Opportunity Commission as follows:
q
1. White - (Not of Hispanic origin) - Persons having origins in any of the original peoples of Europe, North
Africa, or the Middle East (includes all countries within the Arabian peninsula; excluding countries within the
Indian Subcontinent).
q
2. Black - (Not of Hispanic origin) - Persons having origins in any of the Black racial groups of Africa.
q
3. Hispanic - Persons having origins in the original people of Spain and persons of Mexican, Puerto Rican,
Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
q
4. Asian or Pacific Islanders - Persons having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian Subcontinent, or the Pacific Islands.
q
5. American Indian or Alaskan Native - Persons having origins in any of the original peoples of North
America, and who maintain cultural identification through tribal affiliation or community recognition.
q
6. Cape Verdean - Persons having origins in the Cape Verde Islands.
q
7. Two or More Races – All persons who identify with more than one of the above five races. NOTE: If you
check the “Two or more races box, please check ALL boxes that identify your race/ethnicity.
How did you learn about the job for which you are applying? (Please limit your selection to ONE)
q
Social Media/Online Website (name)
q
Community Agency (name)
q
College/University (name)
Walk-In
City Employee
City of Brockton Website
Employment Agency
q
Other (Please indicate)
Page 5
VOLUNTARY SELF – IDENTIFICATION OF DISABILITY
Why are you being asked to complete this form?
Because we do business w
ith the government, we must reach out to, hire, and provide equal opportunity to qualified
people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have or ever had a
disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job,
any answer you give will be kept private and will not be used against you in any way.
How do I know if I have a disability?
You are considered to
have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such impairment or medical condition.
Examples of disabilities include, but are not limited to:
·
Blindness
·
Autism
·
Bipolar disorder
·
Post-traumatic stress disorder (PTSD)
·
Deafness
·
Cerebral palsy
·
Major depression
·
Obsessive compulsive disorder (OCD)
·
Cancer
·
HIV/AIDS
·
Multiple sclerosis (MS)
·
Impairments requiring the use of a wheelchair
·
Diabetes
·
Epilepsy
·
Schizophrenia
·
Muscular
dystrophy
·
Missing limbs or partially
missing limbs
·
Intellectual disability (previously called mental
retardation)
Please check one of the boxes below:
q
Yes, I have a disability (or previously had a disability)
q
No, I don’t have a disability
q
I don’t wish to answer
VOLUNTARY SELF – IDENTIFICATION OF VETERAN STATUS
Veteran status is defined as follows by the U.S. Department of Veterans Affairs. Please check all that apply.
Armed Forces Serv
ice Medal Veteran - a veteran who, while serving on active duty in the U.S. military, ground,
naval or air service, participated in a United States military operatio
n for which an Armed Forces service medal was
awarded pursuant to Executive Order 12983 (61 Fed. Reg. 1209).
Disabled Veteran - (i) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or
who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the
Secretary of Veterans Affairs, or (ii) a person who was discharged or released from active duty because of a service-
connected disability.
Recently Separated Veteran - a veteran during the three-year period beginning on the date of such veteran’s
discharge or
release from active duty in the U.S. military, ground, naval or air service.
Other Protected Veteran – a veteran who
served on active duty in the U.S. military, ground, naval or air service
during a war, or in a campaign or expedition for which a campaign badge has been authorized. Information required to
make this determination is available at:
http://www.opm.gov/veterans/html/vgmedal2.htm or by calling (301) 306 6752
and requesting that a copy of the list be mailed to you.
Active Duty Wartime Campaign Badge Veteran – An “active duty wartime or campaign badge veteran” means a
veteran who served on active duty in the U.S. military, ground, naval or air
service during a war, or in a campaign or
expedition for which
a campaign badge has been authorized under the laws administered by the Department of
Defense.
I
am a protected veteran, but choose not to self-identify the classification to which I belong.
Page 6
I don’t wish to answer.
I am not a protected veteran.
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Completed 2 August 2020

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