CITY OF WALHALLA
EMPLOYMENT APPLICATION
PO BOX 1099 WALHALLA, SOUTH CAROLINA 29691

 

DATE ___________________                                     POSITION APPLIED FOR ______________________

 

___________________________________________________________________________________

LAST NAME                                                        FIRST NAME                                                       MIDDLE NAME

 

___________________________________________________________________________________
CURRENT ADDRESS                                         CITY, STATE                                         ZIP CODE

 

___________________________________________________________________________________
TELEPHONE NUMBERS                                                                  SOCIAL SECURITY NUMBER

 

___________________________________________________________________________________
DRIVERS LICENSE NUMBER                          DATE OF BIRTH                  DATE AVAILABLE TO START

 

Have you filed an application with City of Walhalla before?                           ___Yes                 ___No
Dates _________________________

Have you been employed with the City of Walhalla before?                          ___Yes                 ___No
Dates_________________________
Are you currently employed?                                                                                     ___Yes                 ___No
Are you under any employment contract?                                                            ___Yes                 ___No
May we contact your present employer?                                                              ___Yes                 ___No
Are you a United States citizen?                                                                                 ___Yes                 ___No
Are you currently on layoff, subject to recall?                                                       ___Yes                 ___No
Can you travel if required?                                                                                           ___Yes                 ___No
Do you have a commercial driver’s license?                                                          ___Yes                 ___No
Are you able to work ______ Full-time  _______ Part-time _______ Temporary  ____ Shifts

 

Have you been convicted of a traffic violation within the past 10 years?  ___ Yes                 __ No

Details _____________________________________________________________________

Have you been convicted of a misdemeanor, pled guilty or no contest?   ___ Yes                 __ No
Details _____________________________________________________________________
Are you currently under any domestic or restraining order?                          ___ Yes                 __ No
Details _____________________________________________________________________

 

Page 2

 

EDUCATION

NAME AND ADDRESS OF SCHOOL                              COURSE OF STUDY           YEARS                   DIPLOMA/
COMPLETED       DEGREE

 

HIGH SCHOOL

 

__________________________________________________________________________________

COLLEGE OR UNIVERSITY

__________________________________________________________________________________

POST GRADUATE

__________________________________________________________________________________

EMPLOYMENT HISTORY

List current or most recent position first.  If necessary, continue on a separate sheet.  May attach resume in addition to completing the application.

__________________________________________________________________________________
EMPLOYER                                          ADDRESS                                                             PHONE NUMBER

__________________________________________________________________________________
DATES EMPLOYED            JOB TITLE                             SALARY/RATE                                    SUPERVISOR

__________________________________________________________________________________
DUTIES OR WORKED PERFORMED

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________
REASON FOR LEAVING
 

Page 3

 

Employment History cont.

_____________________________________________________________________________________
EMPLOYER                                          ADDRESS                                                             PHONE NUMBER

_____________________________________________________________________________________
DATES EMPLOYED            JOB TITLE                             SALARY/RATE                                    SUPERVISOR

_____________________________________________________________________________________
DUTIES OR WORKED PERFORMED

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
REASON FOR LEAVING

_____________________________________________________________________________________
EMPLOYER                                          ADDRESS                                                             PHONE NUMBER

_____________________________________________________________________________________
DATES EMPLOYED            JOB TITLE                             SALARY/RATE                                    SUPERVISOR

____________________________________________________________________________________
DUTIES OR WORKED PERFORMED
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
REASON FOR LEAVING

 

 

 

 

 

Page 4

REFERENCES

1.

_____________________________________________________________________________________
NAME                                                   RELATIONSHIP                                                                                  PHONE
_____________________________________________________________________________________
ADDRESS

 

  1. ___________________________________________________________________________________
    NAME RELATIONSHIP PHONE
    _____________________________________________________________________________________
    ADDRESS

 

  1. ___________________________________________________________________________________
    NAME RELATIONSHIP PHONE
    _____________________________________________________________________________________
    ADDRESS

Describe any specialized training, apprenticeship, skill and extracurricular activities, including job related training received in the military.

_____________________________________________________________________________________

_____________________________________________________________________________________

 

 

List professional, trade, business, or civic activities and offices held.  You may exclude memberships that would reveal gender, race, religion, creed, national origin, age, ancestry, disability, or other protected status.
_____________________________________________________________________________________

_____________________________________________________________________________________

Summarize any special job related skills and qualifications.
_____________________________________________________________________________________

_____________________________________________________________________________________

 

AUTHORIZATION FOR RELEASE OF INFORMATION

 

TO WHOM IT MAY CONCERN: I am an applicant for a position with the City of Walhalla (COW).  The department needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold this position for which I applied.  It is in the public’s interest that all relevant information concerning my personal employment and credit history be disclosed to this agency.

 

I hereby authorize any representative of the COW 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 to the bearer.  I do hereby authorize a review of full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of COW, 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 pursing a background investigation that may provide pertinent data for COW to consider in determining my suitability for employment in that department.  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, my credit and financial records, 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 attorney’s 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 investigations and discipline, including 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 the organization, including its officers, employees or related personnel, both individually and collectively , from any and all liability for damages of whatever kid, which may at anytime 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 COW regardless of any agreement I may have previously made with you to the contrary.

 

For consideration of the COW acceptance and processing of my application for employment, I agree to hold your organization, 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 employee me with the COW.  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 disclosure of records and I waive those rights with the understanding that information furnished will be used by the COW in conjunction with employment procedures.

 

A photocopy or FAX copy of this release form will be as 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 sixty (60) days 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.

 

 

_______________________________________________                                       __________________________
APPLICANT SIGNATURE                                                                                                       DATE

 

______________________________________________                                         __________________________
APPLICANT NAME                                                                                                                SOCIAL SECURITY NUMBER

 

________________                           _________________________________________________________________

DATE OF BIRTH                                     APPLICANT ADDRESS

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