Fillable General-Application - Application_page1

Fill Online, Printable, Fillable, Blank General-Application - Application_page1 Form

Use Fill to complete blank online CITY OF FALLON (NV) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

General-Application - Application_page1

On average this form takes 48 minutes to complete

The General-Application - Application_page1 form is 5 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 188 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Fallon

BROWSE CITY OF FALLON (NV) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1 revised 10/14/19
EMPLOYMENT APPLICATION
City of Fallon
55 West Williams Ave.
Fallon, Nevada 89406
Clerk’s Office (775) 423-5104
Fax (775) 423-8874
Applicants are considered for all positions without regard to race, color, religion, creed, gender, National origin,
disability, marital or veteran status, sexual orientation or any other legally protected status.
Position
Applied
For Date of Application
Full-Time
Part-Time
NAME____________________________________________________________________
ADDRESS
PHONE NUMBER EMAIL ADDRESS
LAST 4 OF SOC. SEC. NUMBER DRIVER’S LICENSE STATE & NUMBER
Have ever filed an application with us before? Yes No If yes, when ____________________
Have you been previously employed by the City of Fallon? Yes No If yes, when ____________________
Do you have any relatives employed by the City of Fallon? Yes No
If yes, please provide name(s), relationship and department they are employed in:
Are you eligible to work in the United States? Yes No Verification will be required prior to employment.
Emergency Contact ____________________________________________ Phone Number____________________
RESIDENCES – Beginning with your current address, list chronologically all residences over the past 15 years.
Street Address City State
Dates From To
Street Address City State
Dates From To
Street Address City State
Dates From To
(Attach additional pages if necessary)
Date Received
2 revised 10/14/19
EMPLOYMENT HISTORY - List chronologically, starting with the most recent, all present and past employers within the past
15 years. Include part-time and self-employment. For any unemployed periods, show dates. If additional space is needed,
attach to this application.
Employer Name:
Phone Number (including area code)
Address (including Zip Code)
Ending Date
City
Zip Code
Job Title
Starting Salary $ | Ending Salary $
Supervisors Name
Work Performed
Reason for Leaving
Were you disciplined, counseled, warned, discharged or asked to resign because of job performance or for violating the company rules? Yes No
If yes, explain:
Employer Name:
Phone Number (including area code)
Address (including Zip Code)
Ending Date
City
Zip Code
Job Title
Starting Salary $ | Ending Salary $
Supervisors Name
Work Performed
Reason for Leaving
Were you disciplined, counseled, warned, discharged or asked to resign because of job performance or for violating the company rules? Yes No
If yes, explain:
Employer Name:
Phone Number (including area code)
Address (including Zip Code)
Start Date
Ending Date
City
State
Zip Code
Job Title
Starting Salary $ | Ending Salary $
Supervisors Name
Work Performed
Reason for Leaving
Were you disciplined, counseled, warned, discharged or asked to resign because of job performance or for violating the company rules? Yes No
If yes, explain:
3 revised 10/14/19
REFERENCES - Give at least three (3) references, not relatives, who are responsible adults of reputable standings in their
communities, such as householders, property owners, business or professional persons, who have known you well during
the past five (5) years, and three (3) social acquaintances in your own age group.
Business/Professional References – (Supervisors and/or Co-Workers are Acceptable)
1.
( )
Name
Business Name
Address
Phone#
2
( )
Name
Business Name
Address
Phone#
3
( )
Name
Business Name
Address
Phone#
Personal References-(Known for at Least 5 Years)
1.
( )
Name
Business Name
Address
Phone#
2
( )
Name
Business Name
Address
Phone #
3.
( )
Name
Business Name
Address
Phone#
SOCIAL SITE INFORMATION
Do you currently have a profile with any social websites? Yes No If yes, indicate below.
□ Twitter
□ Instagram
□ Facebook
□ Other Sites
EDUCATIONAL HISTORY - Submit a copy of your high school diploma, GED, college diploma and professional certifications
High School
09 10 11 12
College
Hours
Degree
College
Hours
Degree
Graduate, Professional, Business, or Trade School
Hours
Degree/Certificate
Job related licenses, certifications, trainings or skills
Branch of Service Dates Served Type of Discharge
Are you currently a member of the National Guard or other Reserve Unit?
While serving in the military, did you receive any discipline, court
martial, or company punishment? Yes No
4 revised 10/14/19
TRAFFIC HISTORY - In the past ten (10) years, have you received any traffic or parking citations? Yes No
Has your driver's license ever been suspended or revoked? Yes No If yes, please provide the following information:
Date
Charging Agency
Violation
Guilty Not Guilty
Paid Fine
Details
Explanations:
Have you ever been licensed in another state? If so, which states?
Yes
ARREST HISTORY - Have you ever been convicted of a Misdemeanor or Felony Offense? No If yes,
provide the following information:
Date
Charging Agency
Violation
Sentencing Details
Additional explanation:
Have you ever been a part to any civil action in Justice Court, District Court or Federal Court? (Example-Small Claims,
Divorce, Bankruptcy, Lawsuit) Yes No If yes, provide details.
MILITARY RECORD
Have you ever served in the Armed Forces of the United States? Yes No
If yes, explain:
ATTACH COPY OF YOUR DD-214
5 revised 10/14/19
AUTHORITY TO RELEASE INFORMATION THIS FORM MUST BE SIGNED!
Read the following release form carefully and enter your signature and the date in the designated spaces.
TO WHOM IT MAY CONCERN:
I am an applicant for a position with the City of Fallon, Nevada. The City needs to investigate my employment background and
personal history to evaluate my qualifications to hold the position for which I applied. It is in the public's interest that all relevant
information concerning my personal and employment history is disclosed to the City of Fallon.
I hereby authorized any representative of the City of Fallon bearing this release to obtain any information in your files pertaining
to my employment records and I hereby direct you to release such information upon request of the bearer. I do hereby authorize
a review of and full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of the
City of Fallon, whether said records are of public, private, or confidential nature. The intent of this authorization is to give my
consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free
access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that
may provide pertinent data for the City of Fallon to consider in determining my suitability for employment. It is my specific intent to
provide access to personnel information, however personal or confidential it may appear to be.
I consent to your release of any and all public and private information that you may have concerning me, my work record, my
background and reputation, my military service records, educational records, my financial status, my criminal history record,
including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by
or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in
any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations,
and any internal affairs investigation and discipline, including any files which are deemed to be confidential, and/or sealed.
I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information
requested, including any liability or damage pursuant to any state or federal laws. I hereby release you, as the custodian of such
records of organization, including its officers, employees, or related personnel both individually and collectively, from any and all
liability for damages of whatever kind, which may at any time 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 direct you to release such
information upon request of the duly accredited representative of the City of Fallon regardless of any agreement I may have
made with you previously to the contrary. The organization requesting the information pursuant to this release will discontinue
processing my application if you refuse to disclose the information requested.
For and in consider of the City of Fallon's acceptance and processing of my application for employment, I agree to hold the City
of Fallon, its agents and employees harmless from any and all claims and liability associated with my application for employment
or in any way connected with the decision whether or not to employ me with the City of Fallon. I understand that should
information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the
proper authorities.
I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and to
disclosure of records, and I waive those rights with the understanding that information furnished will be used by the City of Fallon
in conjunction with employment procedures. A photocopy or FAX copy of this release form will be valid as an original thereof,
even though the said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for a period of one (1) year from the date of my signature. Should there be any questions as to the validity of
this release, you may contact me at the address listed on this form. I agree to pay any and all charges or fees concerning this
request and can be billed for such charges at the address listed on this form. I agree to indemnify and hold harmless the person
to whom this request is presented and his agents and employees, from and against all claims, damages, losses and expenses,
including reasonable attorney's fees, arising out of or by reason of complying with this request.
Print Name
Signature
Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

General-Application - Application_page1

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document