Position Applying For:

Position Title Stated on Job Announcement

Announcement Number:

XXXX-XXXX (example - 2003-0001)

First Name:

Middle Name:

Last Name:

Former Last Name or
Maiden Name:

Address 1:

Address 2:

City:

State:

None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Work Phone:

XXX.XXX.XXXX (example 972.864.6000)

Home Phone:

XXX.XXX.XXXX (example 972.864.6000)

Cell / Pager Number:

XXX.XXX.XXXX (example 972.864.6000)

Email

Date Available to Start Work:

mm/dd/yy (example 01/01/03)

I preferred to be notified about the status of my application by:

U.S. Mail      Email

Education

Your educational record will be considered only to the extent that it is relevant to the position sought.
All education listed is subject to verification. Click on highest grade completed.

Grade School

1   2  3  4   5   6  7  8

High School

1   2  3  4

College

1   2  3  4

Graduate School

1   2  3  4

Computer Skills: Windows MSWord Excel Access PowerPoint Other:

Machines or Equipment Operated:

Special Licenses or Registrations:

Indicate any foreign languages you can speak, read, and/or write:

Employment History

List your employment experience, including military experience, beginning with your current or last position for the past 10 years.

Are you presently employed? Yes No  

If yes, may we contact your present employer? Yes No Later

1. Employer:

Dates of Employment: From To   month/year (example - 02/03)

Employer's Address:

Employer's Telephone Number: XXX.XXX.XXXX (example 972.864.6000)

Position Title:  Starting Salary $   Ending Salary $

Full Time Part Time Seasonal Temporary

Supervisor's Name: Supervisor's Title:

Reason For Leaving/Type of Military Discharge:

2. Employer:

Dates of Employment: From To   month/year (example - 02/03)

Employer's Address:

Employer's Telephone Number: XXX.XXX.XXXX (example 972.864.6000)

Position Title:  Starting Salary $   Ending Salary $

Full Time Part Time Seasonal Temporary

Supervisor's Name: Supervisor's Title:

Reason For Leaving/Type of Military Discharge:

3. Employer:

Dates of Employment: From To   month/year (example - 02/03)

Employer's Address:

Employer's Telephone Number: XXX.XXX.XXXX (example 972.864.6000)

Position Title:  Starting Salary $   Ending Salary $

Full Time Part Time Seasonal Temporary

Supervisor's Name: Supervisor's Title:

Reason For Leaving/Type of Military Discharge:

4. Employer:

Dates of Employment: From To   month/year (example - 02/03)

Employer's Address:

Employer's Telephone Number: XXX.XXX.XXXX (example 972.864.6000)

Position Title:  Starting Salary $   Ending Salary $

Full Time Part Time Seasonal Temporary

Supervisor's Name: Supervisor's Title:

Reason For Leaving/Type of Military Discharge:

5. Employer:

Dates of Employment: From To   month/year (example - 02/03)

Employer's Address:

Employer's Telephone Number: XXX.XXX.XXXX (example 972.864.6000)

Position Title:  Starting Salary $   Ending Salary $

Full Time Part Time Seasonal Temporary

Supervisor's Name: Supervisor's Title:

Reason For Leaving/Type of Military Discharge:

I certify the statements made by me in this application are true, complete, and correct to the best of my knowledge, and are made by me in good faith. I understand that any falsifications, misrepresentations or omissions of fact in this application may be cause for my elimination from consideration for hire, or, if already hired, cause for my dismissal, regardless of the time that elapses before such false information is discovered.

I understand that all applicants chosen for employment must undergo a medical examination, including a drug screen, and other job related testing, given at the Town’s expense.

I understand and agree that employees are “at-will” and employment with the Town of Flower Mound is for no definite period of time, and that wages, benefits, and conditions of employment can be changed at any time.

I understand that consideration of my employment in this position is contingent upon the result of a reference and background check, and a post-offer medical examination and drug screen.

Applicant's Signature:
(A signature is acquired by typing your name.)

Date:

mm/dd/yy (example 01/01/03)

Background Information

This page will be detached from your application upon receipt and will be kept on file for background investigation purposes. This information will not be used for making interviewing decisions. Please complete all information. Failure to answer all questions fully and accurately may result in loss of employment opportunities.

First Name:

Middle Name:

Last Name:

Former Last Name or
Maiden Name:

Social Security Number

XXX-XX-XXX (example 123-45-6789)

Date of Birth:

mm/dd/yy (example 01/01/03)

Drivers License Number:

State:

None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Expiration Date:

Type of License Held:

A-CDL B -CDL Class C

Are you over the age of 18? Yes No  

Have you ever been employed by the Town of Flower Mound? If yes, please provide the position title(s) you held and your dates of employment below. Yes No  

Do you have relatives working for the Town of Flower Mound or serving on the Town Council? If yes, please provide their name(s) and relationship to you below. Yes No  

Are you a U.S. Citizen or do you have a legal right to work in the United States? It will be necessary to submit documents as required by law to verify your identification and employment authorization upon employment. Yes No  

Have you been issued a citation for any moving traffic violation(s) within the past three years for which you were convicted? If yes, please provide the charge, date, and location for these incidents below. Yes No  

Have you ever been convicted of a crime other than a Class C traffic offense? If yes, please provide the charge, date and location of the incidents below. Yes No  

Failure to answer the above questions truthfully may result in a loss of employment opportunity. Traffic violations or other convictions will not necessarily disqualify you from employment. Your information will be reviewed in relationship to the requirements of the job for which you are applying.

Remarks:

References

List two (2) professional references (i.e., co-workers, subordinates, or supervisors) and two (2) personal references (i.e., friend, neighbor, or acquaintance) excluding relatives.

AUTHORIZATION FOR RELEASE OF PERSONAL DATA AND AUTHORIZATION
TO CONDUCT MEDICAL EXAMINATION AND DRUG TESTS

I, the undersigned, hereby authorize and request any present or former employer, educational institution, organization, law enforcement agency, financial institution, consumer reporting agency, or other persons having personal knowledge concerning my work record, school record, driving record, military record, reputation, financial or credit status, criminal history, or copies of such documents to furnish the Town of Flower Mound and/or its representatives, with any and all information in their possession regarding these matters, in connection with an application for or retention of employment. Furthermore, I hereby release from liability and hold harmless all persons, organizations, agencies or institutions supplying this information to the Town of Flower Mound and/or its representatives. I also hereby release from liability and hold harmless the Town of Flower Mound, Texas, relative to any documentation released to it pursuant to this Authorization. A photocopy of this Authorization is as effective as the original.

I hereby authorize the Town of Flower Mound and its agents to conduct any medical examination they deem necessary. I hereby authorize the release to the Town of Flower Mound all results of any medical examinations performed by any doctors or clinics to which I have been referred. This information is authorized to be used by the Town of Flower Mound for the sole purpose of employment-related matters.

I hereby authorize the Town of Flower Mound and its agents to conduct any urine drug tests they deem necessary. I understand that proper “chain of custody” procedures shall be maintained and that the testing shall be conducted by a NIDA Certified laboratory. I hereby authorize the release to the Town of Flower Mound all results of any drug tests performed by any doctors, clinics, or laboratories to which I have been referred. This information is authorized to be used by the Town of Flower Mound for the sole purpose of employment-related matters.

First Name:

Middle Name:

Last Name:

Applicant's Signature
(A signature is acquired by typing your name.)

Date

mm/dd/yy (example 01/01/03)

Parent or Guardian Signature
(If applicant is under age 18)
(A signature is acquired by the Parent
or Guardian typing their name.)

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

The commitment of the Town of Flower Mound to a policy of equal employment opportunity requires that certain information be gathered and maintained for government record-keeping requirements only. This page will be detached from your application immediately upon receipt, and this information will not be used for making interviewing or hiring decisions. Your completion of this page is optional; refusing to provide this information will not affect the evaluation of your application. Your cooperation in this effort would, however, be greatly appreciated.

Position Applying For:

Position Title Stated on Job Announcement

Announcement Number:

XXXX-XXXX (example - 2003-0001)

Date of Birth:

mm/dd/yy (example 01/01/03)

Male Female

Race/National Origin:

Caucasian/White Black/Non Hispanic Hispanic Asian/Pacific Islander American Indian/Alaskan Native

Other

Education Level:
Click on Highest Grade Completed:

Grade School

1   2  3  4   5   6  7  8

High School

1   2  3  4

College

1   2  3  4

Graduate School

1   2  3  4

How did you find out about this vacancy?

Professional Organization  Walk-In  Town Employee  Job Fair/Recruiter  Friend or Relative
College or School Internet  Newspaper:   Other: