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City of Storm Lake Job Application

APPLICATION FOR EMPLOYMENT
The City of Storm Lake considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status, sexual orientation, and/or any other legally protected status. Applications filed with the City of Storm Lake are public records unless otherwise stated in the Job Posting or Announcement. Personal Information including social security number and driver's license number are protected from public disclosure in all cases.
Position(s) Applied for*
Date of application*
Date of application
How did you learn about this opening?
Last Name*
First Name*
Middle Name
Address: Number, Street*
City, State*
Zip Code*
Phone Number (s)
E-mail Address
If you are under 18 years of age, can you provide required proof of your eligibility to work?*
Have you ever filed an application with us before?*
If yes give date and position:
Have you ever been employed by us before?*
If yes, give date and position:
Are you currently employed?*
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration "Status?"*
On what date would you be available for work?*
On what date would you be available for work?
Are you available to work? check all that apply*
1. Full Time
2. Part Time
1. Temporary/Seasonal
2. Shift Work
Are you currently on "lay-off" status and subject to recall?*
Can you travel if the job requires it?*
Have you been convicted of a felony within the last 7 years?*
If yes, please explain:
Conviction will not necessarily disqualify an applicant from employment.
THE CITY OF STORM LAKE IS AN EQUAL OPPORTUNITY EMPLOYER THE CITY OF STORM LAKE IS A DRUG FREE WORKPLACE
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Education/Training

High School
City and State
Number of years completed
Diploma
GED
College
City and State
Number of years completed
Degree
Majors/Minors
Other (Specify)
Indicate any other languages you can speak, read and /or write
Please list language and indicate fluent, good or fair
Describe any specialized training, apprenticeship, skills, and extra-curricular activities:
Complete this section if you served in the U.S armed forces
Branch of Service
Period of Active Duty
(Month & Year):
To
From
Rank at discharge
Date of final discharge
Describe your duties and any special training:
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 other protected status:
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Employment Experience

Start with your present or last job. Include any job-related military service assignments or volunteer activities. (You may exclude organizations which indicate gender, race, religion, national origin, age, ancestry, disability, or other protected status.) You may attach separate pages if additional space is needed.
Employer, Address, City State Zip
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Phone number
Job Title
Supervisor
Hourly Rate/Salary
Reason for Leaving
Work Performed
Employer, Address, City, State, Zip
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Phone number
Job title
Supervisor
Hourly Rate/Salary
Reason for leaving
Work performed
Employer, Address, City, State, Zip
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Phone number
Job title
Supervisor
Hourly Rate/Salary
Reason for leaving
Work Performed
References
Name
Phone
Address, City, State ,Zip
Name
Phone
Address, City, State, Zip
Name
Phone
Address, City, State, Zip
Applicant's Statement
I certify that the information and answers given herein are true and complete to the best of my knowledge. I authorize the City of Storm Lake to investigate all of the statements contained in this application for employment as may be necessary for 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 applications 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 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 the City Administrator or (his/her) designee. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the City of Storm Lake.
Signature*
Date*
Date
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Release

I hereby authorize the Iowa Department of Transportation to release my driving history record to the City Clerk's Office of the City of Storm Lake for the purpose of a pre-employee background check. I Consent to the City of Storm Lake to conduct a full query of the FMSCA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
Signature*
Social Security Number*
Date of Birth*
Printed Name*
Date*
Date
Drivers Liscense Number*
Class
State where issued*
Expiration Date:
Applicant's (for Employment) Waiver of Liability and Release Form
In order for the City of Storm Lake to make a thorough investigation of my background, health, family history, personal habits, and reputation for the purpose of determining my fitness and suitability for employment with the City, I,:
First Name
Last Name
hereby release from liability and agree to hold harmless from liability the City of Storm Lake, its officers, employees, or agents based upon any theory of liability or cause of action relating to any act or failure to act in connection with that investigation. This specifically includes inquiries into all aspects of my background which are permitted by law, and is with the understanding the the City will not make any inquiry into my state of health until such time as the City shall have offered me a job subject to successfully passing a physical or other health background investigation which the City may elect to conduct. I further authorize any present or former employer, school, health care provider or other person, including all of their officers, employees, or agents to release any information they may have about me to the City of Storm Lake and I hereby agree to hold harmless all such entities or persons from any liability under any theory or cause of action relating to the release of any information about me.
I specifically waive the privileges I have selected below:
1. Attorney-Client
2. Accountant-Client
1. Doctor-Patient
2. Clergyman-Patient
1. Husband-Wife
This Release and Hold Harmless Agreement shall be binding upon myself, my beneficiaries and heirs, my personal representative, and any successors and assigns.
Date*
Date
Signature of Applicant (must be an original signature)*
Upload Cover Letter
Upload Resume
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Email address

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City of Storm Lake Job Application

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