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Position applying for

Date*
Date
Position applied for:
Dept:*
Availability*
1. Full Time
2. Part Time
3. Seasonal
Full Name*
Home Phone:*
Work Phone:
Address*
City*
State*
Zip Code*
Have you ever been employed with us before?*
1. Yes
2. No
If yes, provide details here.
Title of Position held:
Termination Date:
Termination Date:
Reasons for leaving:
List any of your relatives who currently work for the City of Laconia.
Name
Department
Relationship
Name
Department
Relationship
Name
Department
Relationship
If you are under 18 years of age, can you provide required proof of your eligibility to work?*
1. Yes
2. No
Are you a citizen of the United States?*
1. Yes
2. No
If no, can you provide proof that you are eligible to work in the United States, in accordance with the Immigration Reform and Control Act?
1. Yes
2. No
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Education

EDUCATION
Did you receive a high school diploma or GED?*
1. Yes
2. No
Choose highest grade completed.*
High School name*
City, State*
Major
Undergraduate College/University name
City, State
Major
Degree
1. Yes
2. No
Graduate / Professional College / University
City, State
Major
Degree
1. Yes
2. No
Other Education: i.e. Technical, Business
City, State
Major
Degree
1. Yes
2. No
AN EQUAL OPPORTUNITY EMPLOYER
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Skills / References / Misc. information

Military
Have you ever served in the U.S. Armed Forces?*
1. Yes
1. No
If yes, what branch?
Dates of active duty:
Dates of active duty: Start Date
—
Dates of active duty: End Date
Type of discharge?
Rank at discharge:
Describe any training received which would be relevant to the position for which you are applying?
SPECIFIC SKILLS
List technical / professional licenses or certifications you hold:
List office machinery, heavy equipment, vehicles and other machinery you can operate:
Indicate any specialized training you have received:
REFERENCES
List three (3) personal references who are not former employers or related to you:
Name & Occupation*
Address*
Phone*
Relationship*
Name & Occupation*
Address*
Phone*
Relationship*
Name & Occupation*
Address*
Phone*
Relationship*
MISCELLANEOUS INFORMATION
May we share your application with other departments within the City of Laconia?*
1. Yes
2. No
Have you ever applied for a position with us before?*
1. Yes
2. No
If yes, give date and position:
ADDITIONAL INFORMATION
Use this space for any further information you think would help us evaluate your application:
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Employment History

EMPLOYMENT HISTORY
(List most recent employer first. Please account for any gaps in employment record)
Company:*
Your Title:*
Address:*
Employed Date range:*
Employed Date range: Start Date
—
Employed Date range: End Date
City:
State:
Zip Code:
May we contact your present employer?
1. Yes
2. No
Salary or Rate of pay: Starting
Salary or Rate of pay: Ending
Responsibilities:
Supervisor's name:
Phone Number:
Reason for Leaving:
Company:
Your Tilte:
Address:
Employed date range:
Employed date range: Start Date
—
Employed date range: End Date
City:
State:
Zip Code:
Salary or Rate of pay: Starting
Salary or Rate of pay: Ending
Responsibilities:
Supervisor's name:
Phone Number:
Reason for Leaving:
Company:
Your Tilte:
Address:
Employed date range:
Employed date range: Start Date
—
Employed date range: End Date
City
State
Zip Code
Salary or Rate of pay: Starting
Salary or Rate of pay: Ending
Responsibilities:
Supervisor's name:
Phone Number:
Reason for Leaving:
Company:
Your Title:
Address:
Employed date range:
Employed date range: Start Date
—
Employed date range: End Date
City:
State:
Zip Code:
Salary or Rate of pay: Starting
Salary or Rate of pay: Ending
Responsibilities:
Supervisor's name:
Phone Number:
Reason for Leaving:
If needed,please attach additional sheets to include additional employment history.
You may attach Resume here:
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Certification and Agreement

CERTIFICATION AND AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING
I CERTIFY that all entries on this application for employment and attachments are true and complete, and I agree and understand that any falsification of information herein, material half-truths, material misstatements or omissions regardless of their time of discovery, may cause forfeiture on my part to any employment with the City of Laconia. I understand that all information on this application is subject to verification and i consent to references and former employers and educational institutions listed being contacted regarding this application.
I AUTHORIZE the City of Laconia to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, performance, attendance, personal history, disciplinary, arrest and conviction records (both juvenile and adult). Further, I hereby authorize all references, persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume and other documents supplied to me, if any) to provide the City of Laconia any relevant information that may be required to arrive at an employment decision. I understand that the information release is for the City of Laconia's use only.
I RELEASE any individual, including record custodians, from any and all liaility for damages of whatever kind or nature which may, at the time, happen to me as a result of compliance, or any attempts to comoply with this authorization.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
(Date)
(Date)
The City of Laconia is an Equal Opportunity Employer

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Email address

This field is not part of the form submission.
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