Application for Employment

2. Roosevelt City
   255 S State Street <br> Roosevelt, Utah 84066 <br> Phone: 435-722-5001 <br> Fax: 435-722-5000 <br> ut-rooseveltcity.civicplus.com/

   255 S State Street
   Roosevelt, Utah 84066
   Phone: 435-722-5001
   Fax: 435-722-5000
   ut-rooseveltcity.civicplus.com/

3. We consider applicants for all positions without regard to race, color; religion, creed, gender, national origin, age, disability, martial or veteran status, or any other legally protected status.

5. Position Applied For

7. What Department

   1. Administration
   2. Streets
   3. Waterlines
   4. Water Meters
   5. Wastewater
   6. Animal Shelter
   7. Police
   8. Crossing Guard
   9. Roosevelt Aquatic Center
   10. Recreation
   11. Cemetery
   12. Golf Course
   13. Parks
   14. Other

8. If Other Please Specify

9. How did you learn about the position?

   1. Advertisement
   2. Employment Agency
   3. Friend
   4. Relative
   5. Inquiry

13. Last Name

14. First Name

15. Middle Name

17. Physical Street Address

19. City

20. State

21. Zip Code

23. Mailing Address

    1. Same as above

25. Mailing Address

27. City

28. State

29. Zip Code

31. Email

32. Contact Phone Number

33. Best Time to Contact You
    Best Time to Contact You

37. If you are under 18 years of age, can you provide required proof of your eligibility to work?

    1. Yes
    2. No
    3. N/A

39. Have you ever filed an application with us before?

    1. Yes
    2. No

40. Give Date
    Give Date

42. Have you ever been employed with us before?

    1. Yes
    2. No

43. Give Date
    Give Date

45. Do any of your friends or relatives other than spouse work here?

    1. Yes
    2. No

47. If yes, please name the friend or relative.

48. 1. Friend
    2. Relative

49. Department the individual works in

51. Are you currently employed?

    1. Yes
    2. No

52. If yes, may we contact your present employer?

    1. Yes
    2. No

54. Are you prevented from lawfully becoming employed in country because of Visa or Immigration Status?

    1. Yes
    2. No

    Proof of citizenship or immigration status will be required upon employment

58. Date Available for Work
    Date Available for Work

59. What is your desired salary range?

61. When are you available to work?

    1. Full Time
    2. Part Time
    3. Morning
    4. Afternoon
    5. Evening

62. Are you currently on "Lay-Off" status and subject to recall?

    1. Yes
    2. No

63. Can you travel if a job requires it?

    1. Yes
    2. No

67. Education

69. High School

71. Name of School

72. Address of School

74. Course of Study

75. Years Completed

76. Diploma / Degree

78. Undergraduate College

80. Name of School

81. Address of School

83. Course of Study

84. Years Completed

85. Diploma / Degree

87. Graduate / Professional

89. Name of School

90. Address of School

92. Course of Study

93. Years Completed

94. Diploma / Degree

96. Other

97. If Other Please Specify

99. Name of School

100. Address of School

102. Course of Study

103. Years Completed

104. Diploma / Degree

108. Work Experience
     Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

     Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

110. Present / Last Employer

111. Date Started
     Date Started

112. Date Ended
     Date Ended

114. Address

115. Contact Phone Number(s)

117. Job Title

118. Starting Hourly Rate/Salary

119. Ending Hourly Rate/Salary

121. Supervisor

122. Description of Work Performed

124. May we contact Employer?

     1. Yes
     2. No

125. Comments

127. Reason for Leaving

131. Employer

132. Date Started
     Date Started

133. Date Ended
     Date Ended

135. Address

136. Contact Phone Number(s)

138. Job Title

139. Starting Hourly Rate/Salary

140. Ending Hourly Rate/Salary

142. Supervisor

143. Description of Work Performed

145. May we contact Employer?

     1. Yes
     2. No

146. Comments

148. Reason for Leaving

152. Employer

153. Date Started
     Date Started

154. Date Ended
     Date Ended

156. Address

157. Contact Phone Number(s)

159. Job Title

160. Starting Hourly Rate/Salary

161. Ending Hourly Rate/Salary

163. Supervisor

164. Description of Work Performed

166. May we contact Employer?

     1. Yes
     2. No

167. Comments

169. Reason for Leaving

173. Employer

174. Date Started
     Date Started

175. Date Ended
     Date Ended

177. Address

178. Contact Phone Number(s)

180. Job Title

181. Starting Hourly Rate/Salary

182. Ending Hourly Rate/Salary

184. Supervisor

185. Description of Work Performed

187. May we contact Employer?

     1. Yes
     2. No

188. Comments

190. Reason for Leaving

194. Describe any specialized training, apprenticeship, skills and extra-curricular activities that would could be used for this position you are applying for.

196. Describe any job-related training received in the United States Military.

197. If this does not apply to you check N/A

     1. N/A

199. List professional, trade, business or civic activities and offices held.

     You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or protected status.

203. Specialized Skills
     Check all that apply

     Check all that apply

205. Office

     1. Computer
     2. Calculator
     3. Fax Machine
     4. Copier
     5. Scanner
     6. Customer Service Skills
     7. Cash Register
     8. Handling Cash
     9. Filing Forms

206. Computer Software You Are Familiar With and Have Used

     1. Word
     2. Excel
     3. Power Point
     4. Pelorus
     5. Word Perfect
     6. Access
     7. Xpress Bill Pay
     8. Other

207. If Other Please Specify

209. Machinery / Equipment

     1. Backhoe
     2. Dump Truck
     3. Lawn Mower
     4. Weed Eater
     5. Snow Plow
     6. Welder

210. Other Experience In

     1. Water Line Maintenance
     2. Sewer Line Maintenance
     3. Lawn Sprinkler Maintenance

211. Language(s) You Can Speak

     1. English
     2. Spanish
     3. Other

212. If Other Please Specify

214. State any additional information you feel may be helpful to us in considering your application

218. Personal / Professional References
     (Do not include family members or past supervisors)

     (Do not include family members or past supervisors)

220. Name

221. Contact Phone Number

222. Occupation

224. Name

225. Contact Phone Number

226. Occupation

228. Applicant's Statement
     I certify that answers given herein are true and complete. <br> I authorize investigation of all statements contained in this application for employment as be necessary in arriving at an employment decision. <br> This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applicants are being accepted at that time. <br> I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with This organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may may discharge Employee at any time with or without cause. It is further understood that this “at will” employment Relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. <br> In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer. <br>

     I certify that answers given herein are true and complete.
     I authorize investigation of all statements contained in this application for employment as be necessary in arriving at an employment decision.
     This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applicants are being accepted at that time.
     I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with This organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may may discharge Employee at any time with or without cause. It is further understood that this “at will” employment Relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
     In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer.
     

230. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
232. Electronic Signature

233. Date
     Date

Leave This Blank:


234. 1. Receive an email copy of this form.
235. Email address

     This field is not part of the form submission.

236. Submit Submit and Print

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