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2. Name*

   Full Legal Name

3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Date of Application Submission*
    Date of Application Submission
13. Date are you available for work?*
    Date are you available for work?
14. Are you legally eligible for employment in this country?*

    1. Yes
    2. No

    (proof of U.S. citizenship or immigration status will be required upon employment)

18. Education
20. High School:*

    or High School Equivalency Diploma (GED)

21. High School Address:*
22. Dates Attended:*
    Dates Attended: Start Date

    —

    Dates Attended: End Date
24. College Name:

    (if applicable)

25. College Address:

    (if applicable)

26. Dates Attended:
    Dates Attended: Start Date

    —

    Dates Attended: End Date

    (if applicable)

28. Technical School:

    (if applicable)

29. Technical School Address:

    (if applicable)

30. Dates Attended:
    Dates Attended: Start Date

    —

    Dates Attended: End Date

    (if applicable)

32. List special skills or qualifications:
34. List any job related volunteer work, hobbies, or memberships:
36. Have you worked for the City of Shelbyville before?*

    1. Yes
    2. No
37. If so, in what position(s):
38. Have you ever taught swim lessons before?*

    1. Yes
    2. No
40. Are you able to meet the attendance requirement of the position?*

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

    1. Yes
    2. No
42. If yes, please explain:

    (such conviction may be relevant if job related, but does not bar you from employment.)

44. Drivers License # & State*

    or State Issued ID #

48. Employment History

    List most recent or present place of employment

50. Employer #1
51. Address
53. Phone Number
54. Hourly Wage/Salary
55. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
57. Position(s) Held
58. Name of Supervisor
59. May we contact employer?

    1. Yes
    2. No
61. Employer #2
62. Address
64. Phone Number
65. Hourly Wage/Salary
66. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
70. References

    Please list two references other than relatives or previous employers

72. Name*

    First and Last Name

73. Phone Number*
74. Address*
76. Name*
77. Phone Number*
78. Address*
82. Resume Upload
86. Electronic Signature Agreement*

    The job description for the position of Water Safety Instructor for the City of Shelbyville Parks and Recreation Department describes the duties and responsibilities for employment in this position.  I acknowledge that I have received this job description, and understand that it is not a contract of employment.  I am responsible for reading this job description and complying with all job duties, requirements and responsibilities contained herein, and any subsequent revisions.

    1. I agree.
88. Electronic Signature*
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field