Town of Clayton

EMPLOYMENT APPLICATION

Police Department

PRINT or TYPE.

APPLICANT'S NAME (Last)                                      (First)                                                                          (M.I.)

Social Security Number

MAILING ADDRESS  (Number and Street)

Daytime Telephone number

(City)                                                                           (State)                                                                         (Zip Code)

Message telephone number

POSITION FOR WHICH YOU ARE APPLYING

pERSONNEL USE ONLY

1. GENERAL

1. Are you currently employed by the Town of Clayton?

 Yes

 No

1. Are you available to work evenings and weekends if necessary?

 Yes

 No

1. Have you ever been convicted by any court of a felony? (A "YES" answer will not automatically bar you from further consideration--provide details in Item H.)

 Yes

 No

1. Have you been convicted of a misdemeanor in the last five years? (A "YES" answer will not automatically bar you from further consideration--provide details in Item H.)

 Yes

 No

1. Have you ever been dismissed or fired from a position for any reason? (A "YES" answer will not automatically bar you from further consideration--provide details in Item H.)

 Yes

 No

1. Have you ever resigned from or quit a position while under investigation or after being informed that discipline would be taken against you, or during an appeal of a disciplinary action? (A "YES" answer will not automatically bar you from further consideration--provide details in Item H.)

 Yes

 No

1. Are you legally eligible for employment in the United States?

 Yes

 No

1. EXPLANATIONS:

1. Do you possess a valid Driver's License? (If "YES", fill in the information below.)

 Yes

 No

License #:            State Issued by:       

Describe any applicable endorsements or restrictions:       

1. Do you have any relatives who work for the Town of Clayton? (If "YES", provide the name(s) below.)

 Yes

 No

1. EDUCATION

1. Check the highest grade completed:  6    7    8    9    10    11    12

1. If you did not complete high school, do you have a high school equivalency diploma?

 Yes

 No

1. Check the number of years of post-secondary education:  1    2    3    4    5    6     7

Name and Location of Institution

Units Completed

Dates Attended

Course of Study

Degree, Diploma or Certificate Obtained

1. List below valid licenses or certificates of professional or vocational competence relevant to this application.

License/Certificate

License/Certificate Number

Expiration Date

1. EMPLOYMENT HISTORY--Starting with the most recent, describe ALL paid, military, and applicable volunteer experience. If you do not have adequate space on this form to provide a complete work history, please attach a resume.

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

From

To

Job Title

Hours per Week

Overtime Eligible

 Yes    No

Name of Company/Organization

Salary Earned

$               per      

Address

Phone

Duties

Reason for Leaving

1. REFERENCES--Please list three professional references that know about your qualifications.

Name

Address

Daytime Phone

Relationship

1. May we contact your current employer?

 Yes

 No

1. MISCELLANEOUS

1. When will you be available to start work?      

1. How did you hear about this employment opportunity? (Please provide specific name of media whenever possible.)

 Word of Mouth

 Advertisement in:      

 Internet Site:      

 Email from:      

 Other:      

1. NOTICES

1. If the Town of Clayton employs you, you will be required to establish your identity and authorization to work in the United States, as required by the Immigration Reform and Control Act.
2. The Town of Clayton is a drug free work place. You may be required to complete a drug test prior to employment.
3. The Town of Clayton is an equal opportunity employer. Applicants for employment shall be afforded equal opportunity without regard to race, color, religion, national origin, disability, gender, marital status or age.

1. CERTIFICATION

I hereby certify that the information provided by me in this application for employment is true, correct, and complete. I understand that any misstatement, failure to answer fully or omission of fact in this application my result in my not being considered in the selection process or may result in my dismissal after hire. I understand that acceptance of an offer of employment does not create a contractual obligation upon the Town of Clayton to continue to employ me in the future. For determination of my potential employment eligibility, I hereby authorize release of educational, police, criminal and employment information pertinent to the position for which I am applying. I further authorize the Town of Clayton to rely upon and use, as it sees fit, any information received from such contacts.

NAME

Signature

Date