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2. Position(s) Applied For:*
4. First and Last Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Email Address*
15. If you are under 18 years of age, can you furnish a work permit?*

    1. Yes
    2. No
16. Have you ever been employed by the City of Shelbyville before?*

    1. Yes
    2. No
18. Are you legally eligible for employment in the country?*

    1. Yes
    2. No
19. Date Available for Work*
    Date Available for Work

    Date Available for Work
21. Type of employment desired (check all that apply):*

    1. Full Time
    2. Part Time
    3. Temporary
    4. Seasonal
22. Are you able to meet the attendance requirements of the position?*

    1. Yes
    2. No
24. Have you been convicted of a felony in the last seven (7) years?*

    1. Yes
    2. No
26. If yes, please explain:
28. Do you have a valid driver's license?*

    1. Yes
    2. No

    Please be prepared to present upon request.

32. Employment History

    List your last (4) employers, military activity, or volunteer activities, starting with the most recent.

34. Employer:
35. Employer Phone:
37. Address
39. City
40. State
41. Zip Code
43. Job Title
44. Dates of Employment
    Dates of Employment Start Date

    Dates of Employment Start Time

    —

    Dates of Employment End Date

    Dates of Employment End Time
46. Summarize the nature of work performed and job responsibilities:
48. Immediate Supervisor and TItle
50. Reason for Leaving
52. Starting Pay
53. Final Pay
55. Employer #2
56. Employer Phone
58. Address
60. City
61. State
62. Zip
64. Job Title
65. Dates of Employment
    Dates of Employment Start Date

    Dates of Employment Start Time

    —

    Dates of Employment End Date

    Dates of Employment End Time
67. Reason for Leaving
69. Start Pay
70. Final Pay
72. Employer #3
73. Employer Phone
75. Address
77. City
78. State
79. Zip
81. Job Title
82. Dates of Employment
    Dates of Employment Start Date

    Dates of Employment Start Time

    —

    Dates of Employment End Date

    Dates of Employment End Time
84. Reason for Leaving
86. Start Pay
87. End Pay
89. Employer #4
90. Employer Phone
92. Address
94. City
95. State
96. Zip
98. Job Title
99. Dates of Employment
    Dates of Employment Start Date

    Dates of Employment Start Time

    —

    Dates of Employment End Date

    Dates of Employment End Time
101. Reason for Leaving
103. Start Pay
104. End Pay
108. Additional Background Information

     List the name, location, years completed, course of study, and graduation date.

110. High School
112. Years Completed
113. Year Graduated
115. Course of Study
117. College
119. Years Completed
120. Year Graduated
122. Course of Study
124. Additional Education or Certifications
126. References
128. Reference #1:
130. First Name
131. Last Name
133. Email Address
134. Phone Number
136. Relationship
137. Years Known
139. Reference #2
141. First Name
142. Last Name
144. Email Address
145. Phone Number
147. Relationship
148. Years Known
150. Reference #3
152. First Name
153. Last Name
155. Email Address
156. Phone Number
158. Relationship
159. Years Known
163. Resume
164. Cover Letter
168. Acknowledgement

     It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause of cancellation of this application and/or separation for the Employer's service if I have been employed. I give the Employer the right to investigate all references and to secure additional information about me, if job related, I hereby release from liability the employer and its representatives for seeking such information, and all other persons, corporations, or organizations for furnishing such information. The Employer is an Equal Opportunity Employer limiting or excusing any applicant's consideration for employment on a bias prohibited by local, state, or federal law. I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. 

170. First Name

     Please Provide Your Legal Name.

171. Last Name

     Please Provide Your Legal Name.

173. Date of acknowledgement
     Date of acknowledgement

     Date of acknowledgement
Leave This Blank:


177. 1. Receive an email copy of this form.
178. Email address

     This field is not part of the form submission.

179. Submit

* indicates a required field