CITY OF WALHALLA
EMPLOYMENT APPLICATION
PO BOX 1099 WALHALLA, SOUTH CAROLINA 29691
DATE ___________________ POSITION APPLIED FOR ______________________
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LAST NAME FIRST NAME MIDDLE NAME
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CURRENT ADDRESS CITY, STATE ZIP CODE
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TELEPHONE NUMBERS SOCIAL SECURITY NUMBER
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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 _____________________________________________________________________
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EDUCATION
NAME AND ADDRESS OF SCHOOL COURSE OF STUDY YEARS DIPLOMA/
COMPLETED DEGREE
HIGH SCHOOL
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COLLEGE OR UNIVERSITY
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POST GRADUATE
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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.
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EMPLOYER ADDRESS PHONE NUMBER
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DATES EMPLOYED JOB TITLE SALARY/RATE SUPERVISOR
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DUTIES OR WORKED PERFORMED
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REASON FOR LEAVING
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Employment History cont.
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EMPLOYER ADDRESS PHONE NUMBER
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DATES EMPLOYED JOB TITLE SALARY/RATE SUPERVISOR
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DUTIES OR WORKED PERFORMED
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REASON FOR LEAVING
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EMPLOYER ADDRESS PHONE NUMBER
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DATES EMPLOYED JOB TITLE SALARY/RATE SUPERVISOR
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DUTIES OR WORKED PERFORMED
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REASON FOR LEAVING
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REFERENCES
1.
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NAME RELATIONSHIP PHONE
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ADDRESS
- ___________________________________________________________________________________
NAME RELATIONSHIP PHONE
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ADDRESS
- ___________________________________________________________________________________
NAME RELATIONSHIP PHONE
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ADDRESS
Describe any specialized training, apprenticeship, skill and extracurricular activities, including job related training received in the military.
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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.
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Summarize any special job related skills and qualifications.
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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.
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APPLICANT SIGNATURE DATE
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APPLICANT NAME SOCIAL SECURITY NUMBER
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DATE OF BIRTH APPLICANT ADDRESS