APPLICATION FOR EMPLOYMENT
TOWN OF PLYMOUTH • 80 MAIN STREET • TERRYVILLE , CT 06786
THE TOWN OF PLYMOUTH IS AN EQUAL OPPORTUNITY EMPLOYER AND PROVIDER
The Town of Plymouth will not, except in the case of a bona fide occupational qualification or need, or except as otherwise permitted or required by law, discriminate on the basis of race, color, religious creed, age, gender, marital status, sexual orientation, national origin, ancestry, present or past history of mental disorder, mental retardation, learning disability or physical disability, including but not limited to blindness with respect to hiring, compensation, promotion, discharge from employment or other terms and conditions of employment.
Please answer all questions and print legibly.
Have you ever worked under another name? □ Yes □ No If yes, give name_______________________
TELEPHONE: ( ) _________________ MAY WE CONTACT YOU AT WORK? □ Yes □ No
POSITION APPLYING FOR:_________________________________________ DEPT._______________
DATE YOU CAN BEGIN: ___________________SOCIAL SECURITY NUMBER _____________________
ARE YOU AVAIL. TO WORK OVERTIME? □ Yes □ No
ARE YOU OVER THE AGE OF 18? □ Yes □ No. IF UNDER 18, CERTIFICATION MAY BE REQUIRED BY LAW.
ARE YOU A PREVIOUS APPLICANT? □ Yes □ No ARE YOU A PREVIOUS EMPLOYEE? □ Yes □ No
ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? □ Yes □ No
ARE YOU A LICENSED DRIVER WITH A CAR AVAILABLE? (ANSWER ONLY IF APPLICABLE TO THE POSITION YOU ARE APPLYING FOR)? □ Yes □ No
OTHER THAN MINOR TRAFFIC VIOLATIONS, HAVE YOU EVER BEEN CONVICTED OF A CRIME IN THE PAST TEN YEARS WHICH HAS NOT BEEN ANNULLED, EXPUNGED OR SEALED BY A COURT ?
IF YOU ANSWERED YES, PLEASE PROVIDE DETAILS_________________________________________
I UNDERSTAND THAT A CONVICTION WILL NOT AUTOMATICALLY DISQUALIFY ME FOR EMPLOYMENT WITH THE TOWN OF PLYMOUTH, BUT THE TOWN SHALL CONSIDER THE NATURE OF THE CONVICTION AS IT RELATES TO THE JOB DUTIES IN QUESTION AND IN LIGHT OF THE REQUIREMENTS OF STATE AND FEDERAL LAW.
MILITARY SERVICE? □ Yes □ No IF YOU ANSWERED YES, PLEASE PROVIDE DETAILS:
BRANCH OF SERVICE ____________RANK AT DISCHARGE DATES OF SERVICE__________
LIST DUTIES AND ANY SPECIAL TRAINING YOU COMPLETED__________________________________ __________________________________________________________________________________
ADDITIONAL QUALIFICATIONS, SPECIAL TRAINING/EDUCATION, COMPUTER OR OFFICE EQUIPMENT SKILLS AND/OR INDIVIDUAL CAPABILITIES YOU HAVE WHICH PREPARE YOU FOR THE POSITION YOU HAVE APPLIED FOR:______________________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________________
PROFESSIONAL OR LICENSURE INFORMATION (IF APPLICABLE):
LIST ANY PROFESSIONAL CERTIFICATIONS, REGISTRATIONS, OR LICENSES (I.E., COMMERCIAL MOTOR VEHICLE OPERATORS LICENSE) THAT YOU POSSESS, IF APPLICABLE TO THE POSITION YOU ARE APPLYING FOR:
CERTIFICATION/LICENSE #, STATE, AND EXPIRATION DATE_________________________________
HAVE YOU EVER BEEN BONDED? □ Yes □ No IF YES, ON WHAT JOBS?_________________________
PLEASE COMPLETE ALL APPLICABLE ITEMS:
PLEASE LIST ANY ACADEMIC HONORS, SCHOLARSHIPS, MEMBERSHIPS IN HONOR SOCIETIES, ETC.,
WHICH YOU CONSIDER SIGNIFICANT (NOTE: PLEASE EXCLUDE ANY NAMES, TITLE, ETC., INDICATING RACE, SEX, COLOR, NATIONAL ORIGIN OR RELIGION)_______________________________________
OPTIONAL: PLEASE ATTACH A LIST OF REFERENCES.
This application is not a contract of employment in any way. All employment with the Town of Plymouth is on an at-will basis, unless otherwise expressly provided. No official, agent or employee of the Town of Plymouth is authorized to change this employment at-will status. Therefore, either an employee or the Town of Plymouth can end the employment relationship at any time and for any reason.
By your signature below, you acknowledge and aver that there are no misrepresentations, omissions, or falsifications of any kind in the foregoing statements and answers and that the responses given are true, complete and accurate to the best of your knowledge and are made in good faith. Any misrepresentation, omission or falsification in the foregoing statements and answers, or at any time during the application process, is grounds for disqualification from employment, and, if you are hired, without limiting the at-will status of your employment, grounds for immediate discharge.
By your signature below, you also authorize, and discharge from all liability, the Town of Plymouth and all educators, employers and references listed in this application, regarding the furnishing of the Town of Plymouth with information regarding your education, employment history, and any other matter related to your application for employment. The Town of Plymouth will, upon request, supply a copy of this acknowledgment to any educator, employer or reference the Town of Plymouth contacts in regard to this application. The Town of Plymouth reserves the right to conduct all lawful background checks in connection with your application for employment, including but not limited to a credit report check, upon your written request, the Town of Plymouth will supply you with one copy of any such report(s) it receives.
If hired, you agree to comply with all rules, regulations and policies governing employment with the Town of Plymouth, as currently in force and as the same may from time to time be amended, deleted, revised or modified.
TOWN OF PLYMOUTH
80 MAIN STREET • TERRYVILLE , CT 06786
TO: All Courts, Probation Department, Law Enforcement Agencies, Selective Service Boards, Physicians, Hospitals, Employers, Education and other Institutions, and Agencies without exception.
I, __________________________am making application or am being considered for Town of Plymouth employment. As a result, an investigation is being conducted to determine my eligibility. Therefore, you are authorized to release to the Town of Plymouth or its representative any and all information, documentary or otherwise pertaining to me that they may request.
I hereby release, discharge and exonerate the Town of Plymouth , its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing, inspection or collection of such documents, records, and other information or the investigation made by the Town of Plymouth .
A Photostat copy of this authorization will be considered as effective and valid as the original.
Signature_____________________________________________Date of Birth___________________
Sworn to me this __________day of ____________________________________________________
My commission expires____________________________________