Town of Turner, 11 Turner Center Rd, Turner, ME 04282

Employment and Volunteer Application

Pre-service Questionnaire – Equal Opportunity Employer

 

Instructions: Please print and fill out completely.                               Date ______________________________________

 

Personal Information

 

Name______________________________________________________________________________________________________

                      Last                                 First                              Initial

 

Mailing Address______________________________________________________________________________________________

                                                                                                                        City/Town                     State   Zip Code

 

Street Address _______________________________________________________________________________________________

                                                                                                                        City/Town                     State   Zip Code

 

Telephone Numbers ____________________________     ____________________________     ___________________________

                                                    Daytime                                       Evening                                       Mobile

 

Have you ever been employed by this town?  Yes  No   If Yes, when?

 

From_________________________ to _________________________ Position __________________________________________

 

Are you either a U.S. Citizen or do you have the legal right to work in the United States?  Yes  No

 

Valid State License/ID #___________________ Expires____________ Who referred you to us? ___________________________

 

Are you a veteran?  Yes  No     Branch of Service _____________________________      Final Rank _________________

 

Education

Name and Location		Years Completed	Degree Received  and Major Field of Study
High School
College
Trade. Business or Correspondence School
Other

 

List any special skills, special studies/research work or training you possess (machine operator, mechanical skills, computer operator, etc.)_______________________________________________________________________________________________

 

____________________________________________________________________________________________________________

 

Position Desired

 

Position __________________________________ Salary Desired ______________________ When Available ________________

 

Employment History / Experience

 

Are you currently employed?  Yes  No          If yes, may we contact your present employer?  Yes  No

In the table below, list your last three employers starting with the most recent.

 

Employer	Dates (Mo/Yr)	Job Title	Pay Rate	Reason for Leaving
Name	From
Address	To
Name	From
Address	To
Name	From
Address	To

 

References

List three persons, not related to you, who have known you for at least one year.

 

___________________________________________________________________________________________________________Name                                                                            Address                                                             Phone

 

___________________________________________________________________________________________________________

Name                                                                            Address                                                             Phone

 

___________________________________________________________________________________________________________

Name                                                                            Address                                                             Phone

 

Are you willing to submit to a background check?  Yes  No  Are you willing to submit to a drug screen?  Yes  No

 

Have you ever been convicted of a felony or other crimes?  Yes  No (Responding Yes does not automatically disqualify you from employment.) If you answered Yes, please explain the circumstances.______________________________

 

____________________________________________________________________________________________________________

 

Authorization

“I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, falsified statements and omissions on this application shall be grounds for disqualification or if employed, dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give you all information concerning my previous employment or service and any pertinent information they may have, personal or otherwise, and release the municipality from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized municipal representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

 

Date_________________________________ Signature______________________________________________________________

 

^{_______________________________________________________  DO} NOT WRITE BELOW THIS LINE ^{_______________________________________________________}

Interview Notes

Interviewed by_____________________________________________________________ Date ____________________________

 

Remarks
Neatness			Character
Personality			Abilities
Hired	Dept.	Position		Start Date	Pay Rate

 

Approved: 1. ______________________________  2. ______________________________  3. ____________________________

                                                                             Town Manager                             Board of Selectmen Chairman