City of Juneau

APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER

MAIL APPLICATIONS TO: Clerk/Treasurer City of Juneau P.O. Box 163 150 Miller Street Juneau, WI 53039 920-386-4800 – Phone 920-386-4802 – Fax

INSTRUCTIONS: To be filled out by the applicant only. If you are physically unable to fill out this application, you may request reasonable accommodations in completing the form. Answer all questions. Print neatly and accurately. Attach supplements if necessary. Exclude any reference, which may reveal or tend to reveal your race, color, religion, national origin, creed, age, marital status, sex, sexual orientation or disability. · Incomplete applications MAY NOT BE CONSIDERED. · If resume is submitted, DO NOT write “see resume.” · DATE and SIGN this application. · Please list a minimum of prior ten years’ experience and education. · Please complete this application in blue or black ink. Do not type. · You are not required to furnish any information, which is prohibited by federal, state or local law.

TITLE OF POSITION YOU ARE APPLYING FOR: DEPARTMENT: WHERE DID YOU HEAR OF JOB OPENING? Internet ____________________ Radio ________________ Newspaper________________________ Other: ______________________

Name: (Last) (First) (M.I.)	Home Phone: ( ) _ _ _-_ _ _ _
Current Address: (Street) (Apt. #)	Business Phone: ( ) _ _ _-_ _ _ _
(City) (State) (Zip Code)	Can we contact you at this number? Yes (list hours ) No
Permanent Address: (Street) (Apt. #)
(if different that current address)	Social Security Number:
(City) (State) (Zip Code)
Are you legally eligible for employment in the United States? yes no	When will you be available for employment?
Are you at least 18 years of age? yes no Your employment will be subject to verification that you meet state and federal minimum age requirements for the type of work you are applying for and have a valid work permit.	Email Address:

Have you ever been employed by the City of Juneau? yes no If yes: when, in what position, and in what department? List any relatives employed by the City of Juneau or serving as elected or appointed officials: The City of Juneau shall prohibit employment of an individual if he/she would be directly supervising or receiving direct supervision from a family member.
Do you possess a valid driver’s license? yes no Do you possess a valid commercial driver’s license? yes no Type/class: Do you possess any other license? yes no Type:
List any memberships in professional or technical associations:	List any current license or registration as a member of a trade or profession:

Since your 18^th birthday, have you EVER been convicted of any violations of law (or, as a juvenile, been waived into adult court and convicted) or are you now subject to a pending charge? yes no Please list all felonies and any misdemeanors that have occurred in the last 10 years. Please list out each below, including approximate dates.

Date

Location

Charge

Disposition of case

NOTE: In accordance with state law, pending criminal charges or any convictions will not be used or considered unless they are substantially related to circumstances of the particular job.

Did you graduate from high school? yes no

Name of school:

Location of school: If no, have you passed a high school equivalency or GED test? yes no

Location and date of test:

Special skills & qualifications – this information must be provided if you are applying for a position requiring these skills:

Experience transcribing mechanically recorded material? yes no Typing speed (if known) WPM

Experience using a 10-key adding machine? yes no KPM

List any additional office equipment or computer software, which you can operate skillfully:

List any machinery, which you can operate skillfully:

Training beyond high school: College or university, technical, nursing, business college or other schools you have attended.
School name, location and phone number	Dates attended (month/year) From To	Major field	Type of degree received	Credits earned	GPA

Describe any education or training you have had which is not covered above, such as vocational school, correspondence courses, service schools, police or fire academy, in-service training. Please provide dates.

IMPORTANT: You must complete the employment sections of this application. Use additional sheets if necessary. You may attach a resume to further explain your qualifications. Please list a minimum of prior ten years’ experience and education.

Are you currently employed? no yes, since

List any time periods of past unemployment status:

EMPLOYMENT SECTION: (Please start with your most recent position – include military service

From (month & year)	Title of your PRESENT/MOST RECENT position		PRIMARY DUTIES:
To (month & year)	Address:
Full time Part time Temporary	Name and title of supervisor:
Starting salary (indicate yearly, monthly or hourly):	If currently employed, may we contact that employer? yes no, not at this time	Reason for leaving or considering change:
Present salary (indicate yearly, monthly or hourly):	Number of employees you supervise:	Were you involuntarily discharged? yes no

From (month & year)	Title of position		PRIMARY DUTIES:
To (month & year)	Address:
Full time Part time Temporary	Name and title of supervisor:
Starting salary (indicate yearly, monthly or hourly):	Number of employees you supervise:	Were you involuntarily discharged? yes no
Present salary (indicate yearly, monthly or hourly):	Reason for leaving:

From (month & year)	Title of position		PRIMARY DUTIES:
To (month & year)	Address:
Full time Part time Temporary	Name and title of supervisor:
Starting salary (indicate yearly, monthly or hourly):	Number of employees you supervise:	Were you involuntarily discharged? yes no
Present salary (indicate yearly, monthly or hourly):	Reason for leaving:

OTHER EXPERIENCE (Include volunteer experience, internships, and/or jobs, not included in the employment section)
Company Name/Location	Job Title	Dates Employed (month/year)	Annual Salary	Full or part-time

Have you ever been warned/disciplined for any of the following occurrences in any of your previous or current employment?

Attendance yes no If yes, please explain:

Performance problems yes no If yes, please explain:

Inability to get along with others yes no If yes, please explain:

Safety violations yes no If yes, please explain:

Harassment yes no If yes, please explain:

Violent behavior yes no If yes, please explain:

Inappropriate use or possession of alcohol yes no If yes, please explain:

Inappropriate use or possession of a drug yes no If yes, please explain:

Have you ever been suspended from any position? yes no If yes, please explain (include date, location, employer and situation):

Please explain any gaps in employment:

REFERENCES Work or education related (e.g. former employers, supervisors, co-workers, school faculty). No relatives/significant others.
NAME/TELEPHONE/ADDRESS	OCCUPATION	RELATIONSHIP
1.
2.
3.
4.

Applicant Name

AUTHORIZATION AND CERTIFICATION

Please read and initial each of the following statements. If you have questions regarding any of these statements, ask for help prior to initialing and signing the application. Your initials and signature verify that you have read, understand and agree to abide by these statements.

Initial:

______ I authorize any person contacted to provide the City of Juneau any and all information regarding my employment, education and other information concerning any of the subjects covered by the application which may include, but not be limited to, application of employment, performance evaluations, work records, excluding workers compensation if any, wage rates, supervisors’ comments, results of any and all non-medical tests, disciplinary reports or letters, and complaints or allegations regarding any misconduct. I agree to execute release authorization forms as required by the City of Juneau to request employment records from my present and/or former employer(s). I release and hold harmless the City of Juneau, their officers, agents and employees, and the person(s) providing the information from any liability related to the providing of this information.

Initial:

______ I understand that after receiving a conditional offer of employment I may be required to successfully pass pre-employment and post-employment drug tests to gain employment or continue employment with the City of Juneau. I consent freely and voluntarily to participate in required drug tests and/or a pre-employment physical exam at a location selected by the City of Juneau, and consent to the release of the test results to the City of Juneau. I hereby release and hold harmless the City of Juneau, their officers, agents and employees, and the laboratory, their employees, agents and contractors from any liability, whatsoever, arising from the drug tests and/or a pre-employment exam and decisions concerning employment based upon the results of the tests.

Initial:

______ I authorize the City of Juneau, its officers, agents and employees to conduct a background criminal check and a check with the Department of Transportation prior to making a decision regarding employment. I release and hold harmless the City of Juneau, their officers, agents and employees and the person(s) providing the information from any liability related to the performance or results of this check. I recognize that this information will be considered by the City of Juneau only if substantially related to the position applied for.

Initial:

______ If accepted for employment, I agree that my status as an employee depends upon my successful performance. I understand that just as I am free to resign at any time, the City of Juneau reserves that right to terminate my employment at any time. I understand that no representative of the City of Juneau has the authority to make any assurances to the contrary.

Initial:

______ I agree to use such personal protective equipment and devices as may be required by the City of Juneau and to comply with safety rules and requirements. In addition, I understand that the City of Juneau maintains a workplace free from drugs, harassment and violence.

Initial:

______ I understand that nothing contained in this application or any employee handbook, the granting of an interview, or an offer/acceptance of employment constitutes an employment contract.

Initial:

______ I understand that upon successful completion of the standard probation period of 6 months, I have one (1) year to reside within a three-mile radius of the intersection of Main and Oak Street, located in the City of Juneau.

I hereby certify that all statements made on or in connection with my application are true, complete and correct to the best of my knowledge and belief. I understand and agree that any misstatements or omissions of material fact subject me to disqualification, or if hired, dismissal.

Notice – Wisconsin Open Records Law: Under section 19.36(7) of Wisconsin Statutes, the names of the “Final Candidates” must be open to public inspection. The statute also provides that if an applicant does not want his/her name revealed prior to begin date, a “Final Candidate” can do so by making a separate request in writing.

The City of Juneau is committed to the equality of opportunity for all people. It is the policy of the City of Juneau to provide equal employment opportunities for all individuals on the basis of their skills, abilities and qualifications, without regard to race, color, national origin, religion, political affiliation, sex, age, disability, marital status, arrest or conviction record, sexual orientation, disabled veteran or covered veteran status, membership in the National Guard or any other reserve component of the United States or State military forces, use or nonuse of lawful products off the employer’s premises during non-working hours, or any other non-merit factors, except where such factors constitute a bona fide occupational qualification.

Applicant’s signature Date