Action Center // Employment Application

APPLICANT INFORMATION

Last Name*

First Name*

Middle Initial

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Address*

City*

State*

Zip*

Email Address*

Date Available*

MonthDay Year,

Social Security Number*

Are you 18 years or older*

Yes No

Salary Desired*

$

Department*

Requested Position*

May we contact you about other open positions with the Town*

Yes No

How did you hear about us*

Are you a United States Citizen?*

YES

NO

Are you authorized to work in the U.S.*

YES

NO

Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)*

Yes No

Have you ever worked for the Town of Danville before?*

YES

NO

EDUCATION

Highest level of education*

High School*

From*

To*

Did you graduate*

Yes No

College*

From*

To*

Did you graduate/Degree*

Other

Please list any certifications, business, trade, skills, licenses, languages, etc. which may be applicable to the position for which you are applying

REFERENCES

Please Do Not Complete The Following Field

Full Name/Relationship*

Company*

Phone*

Phone Area Code-Phone 3-Phone 4

Email*

Full Name/Relationship*

Company*

Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Email*

PREVIOUS EMPLOYMENT

Current Employer*

Supervisor's name and title*

May we contact your current employer*

Yes No

Company*

Address*

Job Title*

Responsibilities*

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Supervisor*

Starting Salary

$

Ending Salary*

$

Reason for Leaving*

May we contact your previous supervisor?*

YES

NO

MILITARY SERVICE

Branch

From

MonthDay Year,

To

MonthDay Year,

Rank at Discharge

If other than an honorable discharge, explain

EEO INFORMATION

Voluntary Self-Identification of Disability/ Reasonable Accommodation Notice

As an equal opportunity employer, it is our goal to reach out to and hire qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way.

Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

Disability Status

I don't wish to answer

No, I don't have a disability

Yes, I have a disability (or previously had a disability)

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge*

YES

NO

Signature*

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I agree to allow a background check to be completed by the Town of Danville

Date*

MonthDay Year,

Town of Danville, Indiana

The Town of Danville is a great place to live, work and do business.

Employment Application

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

EEO INFORMATION

Voluntary Self-Identification of Disability/ Reasonable Accommodation Notice

DISCLAIMER AND SIGNATURE

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