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CITY OF MUKILTEO 4480 Chennault Beach Road, Mukilteo, Washington 98275 (425) 355-4141, ext. 234 APPLICATION

CITY OF MUKILTEO

4480 Chennault Beach Road, Mukilteo, Washington 98275 (425) 355-4141, ext. 234

APPLICATION FOR EMPLOYMENT

Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, creed, national origin, age or the presence of a sensory, physical or mental disability.

Reasonable Accommodation -- The City of Mukilteo will provide reasonable accommodation to disabled applicants if requested. Please notify the Personnel

POSITION for which you are applying (please print)

DATE:

DATE STAMP:

Office at least two days prior to the need

Name

 

Last)

(First)

(Middle)

Other Names Known By:

Address

 

(Street)

(City)

(State)

(Zip Code)

Telephone Home

Message

Work

Social Security #

-

-

(In accordance with the Federal Privacy Act of 1974, disclosure of Social Security

Number is voluntary. The SSN will be used for identification purposes to ensure that proper records are obtained.)

Are You A Former City Employee? Relatives Employed By The City:

YES o

NO o

Type Of Work Desired:

Full-Time o

Part-Time o

Temporary o

Summer o

Volunteer o

Do You Possess A Valid Driver’s License: YES o Issuing State:

NO o

Are You Claiming Veterans’ Credit? (Police Officer/Firefighter Applicants only)

The City gives Veterans’ Credit (Police Officer/Firefighter Applicants only) as identified by RCW 41.04.010. If you claim Veterans’ Credit, you must complete the Eligibility Worksheet provided in the application packet.

Can You, With Or Without Reasonable Accommodation, Perform The Essential

Functions Of This Job?

High School Graduate? YES o

YES o

NO o

YES o

NO o

NO o

G.E.D. ?

YES o

NO o

School and Location (for High School or G.E.D.)

EDUCATION

Type of Degree & Year Obtained

Type of School

School and Location

Credits Earned

Major

Business or

Technical

Undergraduate

Studies

Graduate

Studies

Special Training/Licenses

Examples Certifications Licenses (CDL, etc.) Keyboarding and/or Typing Speed First Aid/CPR

Please List Special Training & Dates Received (especially those required for this job)

Beginning with your present or most recent employment history, including Military Service. Attach additional pages if necessary. Resumes will not be accepted in place of completing this part of the application.

Employer

Date Employed (MO/YR):

From:

To:

Employer’s Address:

Salary

Current Salary

Most Recent Position:

Supervisor’s Name:

May We Contact? YES o NO o

If Yes, phone number:

Reason for Leaving:

Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

 

Employer

Date Employed (MO/YR):

From:

To:

Employer’s Address:

Salary

Last Salary

Most Recent Position:

Supervisor’s Name:

May We Contact? YES o NO o

If Yes, phone number:

Reason for Leaving:

Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

 

Employer

Date Employed (MO/YR):

From:

To:

Employer’s Address:

Salary

Last Salary

Most Recent Position:

Supervisor’s Name:

May We Contact? YES o NO o

If Yes, phone number:

Reason for Leaving:

Name Used at this Employer, if Different:

Summarize Major Work Duties: (DO NOT write “see resume”)

 

References (Do not list relatives) Name Relationship

Address

Phone

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

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BACKGROUND INFORMATION

Are You Legally Entitled To Work In The United States?

(As required by the Immigration Reform and Control Act of 1986, you will be required to provide acceptable documentation proving identity and right to work in the United States prior to employment.)

YES o

NO o

Have you been convicted of a felony or released from prison within the last seven (7) years, or been convicted of a misdemeanor other than minor traffic offenses within the past three (3) years? YES o NO o If Yes, Please Explain:

A conviction record will not disqualify you for employment unless such record would reasonably affect your fitness for the job for which you have applied.

If I am selected as a finalist applicant, I hereby authorize a City representative to conduct reference and background investigation regarding my work and personal history. I further release and hold harmless from any liability under any and all possible causes of legal action, the City of Mukilteo and all persons with respect to information obtained or provided.

To the best of my knowledge the information herein is true and complete. I further understand that falsification of this application will be grounds for elimination from further consideration or, if employed, for dismissal.

Signature of Applicant

Date

AN INCOMPLETE APPLICATION MAY DELAY PROCESSING YOUR APPLICATION OR DISQUALIFY YOU FROM FURTHER CONSIDERATION.

The City Of Mukilteo Is An Equal Opportunity Employer

We would appreciate the following information. How did you learn of this position? (Check and complete all that apply.)

City Hall Visit

(Check and complete all that apply.) City Hall Visit Notice Posted At Referral by Agency? Internet

Notice Posted At Referral by Agency?

Internet Job Listing URL Other

Job Line (425) 355-4141 (ext 410)

Job Listing URL Other Job Line (425) 355-4141 (ext 410) City Web Site (http://ci.mukilteo.wa.us) Newspaper Name(s)?

City Web Site (http://ci.mukilteo.wa.us)

Newspaper Name(s)? Job Service Listing

Professional Journal

Newspaper Name(s)? Job Service Listing Professional Journal PLEASE COMPLETE (This section will be separated from the

PLEASE COMPLETE (This section will be separated from the application prior to review)

FOR THE PURPOSE OF EFFECTIVELY IMPLEMENTING THE CITY’S AFFIRMATIVE ACTION PROGRAM, WE WOULD APPRECIATE YOUR PROVIDING THE INFORMATION BELOW. THIS IS ENTIRELY VOLUNTARY AND WILL BE KEPT CONFIDENTIAL. IT WILL NOT BE CONSIDERED PART OF YOUR APPLICATION. Please Circle Groups Which Apply To You:

Male

Female

Caucasian

African/American

Hispanic

Asian

Native American

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Other (Please Specify)

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