City of Torrington

Application = for Employment

Date submitted: &= nbsp; &nbs= p; &= nbsp; &nbs= p;

The City of Torrington= does not discriminate in hiring on the basis of race, color, religious cree= d, national origin, sex, age, physical disability or covered veteran status. No question on this application is intended to secure information to be used for such discrimination.

Please return this application to the City of Torrington, Department of Human Resources, 436 East 22^nd Avenue, Torringto= n, WY&nbs= p; 82240 or= fax to (307) 532-2010. If you hav= e any questions, call (307) 532-5666. There is a notary available at City Hall for you convenience.=

I.&n= bsp; = ; Position or type of work applying for: = &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

Have you been employed by the City before? &= nbsp; Yes &= nbsp; No

If yes, in what position? = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

II.&= nbsp; &nbs= p; Personal information

Name: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

&= nbsp; &= nbsp; First = &nb= sp; = &nb= sp; Middle initial = &nb= sp; = Last

Address:&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

&nbs= p; &= nbsp; &nbs= p; Street = &nb= sp; = &nb= sp; = City &= nbsp; &nbs= p; State = Zip

Mailing address (if different): &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

Social Security Number: = &nb= sp; = &nb= sp; Telephone: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

= = Home = &nb= sp; Work &n= bsp; = ;

Valid Drivers’ License # &= nbsp; &nbs= p; &= nbsp; &nbs= p; Class = ; State &nb= sp;

Are you over eighteen (18) years of age? Yes &= nbsp; = No

III. &= nbsp; Availability &= nbsp;

&= nbsp; Date available for work: &nb= sp; = &nb= sp; = F= ull-time Part-time

IV. = Education

	Address, City/State	Major Course or Subject	Circle last year completed	List degree received
High School			1 2 3 4
College			1 2 3 4
Graduate Work			1 2 3 4

List scholastic honors, offices held, and activities in high school and/or colle= ge. &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p;

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &= nbsp; &nbs= p; &= nbsp; &nbs= p;

= V. Specialized Training or Skills

A. = List any special qualifications or certifications/licenses that you feel may qualify you for the position (include seminars, special awards and professional memberships).

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; =

B. = List equipment that you have experience with or knowledge of that y= ou feel may qualify you for the position.

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; <= /u>=

C. = List computer software that you have experience with or knowledge of that you feel may qualify you for the position.

&= nbsp; &nbs= p; &= nbsp; &nbs= p; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

V.&n= bsp; = ; Additional Personal Information

Use the space below to provide additional information necessary to describe your full qualifications.

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = =

VI.&= nbsp; &nbs= p; References

List three (3) individuals (non-relatives) who know your character, ability and experience.

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Name = &nb= sp; = &nb= sp; = &nb= sp; Address &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Telephone

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Name = &nb= sp; = &nb= sp; = &nb= sp; Address &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Telephone

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Name = &nb= sp; = &nb= sp; = &nb= sp; Address &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Telephone

VII.= &nb= sp; Employment Record

In the space provided on the following page, give your employment history beginning with your most recent employer. List all previous employers and in= clude any applicable military and voluntary positions. Use additional sheets of plain pap= er if needed.

May we contact your present employer? Yes &n= bsp; No

1. = Name = & Address of Employer &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

Posit= ion or Title: &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Start= Date: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &= nbsp; End Date: = ; &n= bsp; = ; &n= bsp; = ;

Begin= ning Salary: &nb= sp; = &nb= sp; &= nbsp; Ending Salary: &nb= sp; = &nb= sp; =

&n= bsp; = ; Name/Title of supervisor: &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp;

&= nbsp; &nbs= p; Dutie= s: = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = <= span style=3D'mso-tab-count:9'> &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

&= nbsp; &nbs= p; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp;

&= nbsp; &nbs= p; Reason for leaving: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p;

2.&n= bsp; = ; Name & Address of Employer = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

Posit= ion or Title: &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Start= Date: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &= nbsp; End Date: = ; &n= bsp; = ; &n= bsp; = ;

Begin= ning Salary: &nb= sp; = &nb= sp; &= nbsp; Ending Salary: &nb= sp; = &nb= sp; =

&n= bsp; = ; Name/Title of supervisor: &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp;

&= nbsp; &nbs= p; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp;

&= nbsp; &nbs= p; Reason for leaving: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p;

3.&n= bsp; = ; Name & Address of Employer = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

Posit= ion or Title: &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Start= Date: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &= nbsp; End Date: = ; &n= bsp; = ; &n= bsp; = ;

Begin= ning Salary: &nb= sp; = &nb= sp; &= nbsp; Ending Salary: &nb= sp; = &nb= sp; =

&n= bsp; = ; Name/Title of supervisor: &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp;

&= nbsp; &nbs= p; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp;

&= nbsp; &nbs= p; Reason for leaving: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p;

<= /u>

Certification:= I certify the above information = is correct and truthful. I rea= lize that falsification of any information on this application may be grounds = for rejection of this application or termination of employment. I also give consent for previous employers and personal references to be checked and release the City, previous employers and personal references from any liability arising from disclosure of information concerning my past employment or personal histo= ry. I further understand that accept= ance of this form does not constitute an employment agreement and that failure= to completely fill out this application may result in my disqualification fr= om further consideration.

The City of Torrington believes a viable, satisfied workforce is important to the health and growth of the = area and rout= inely passes along the names and phone numbers of applicants to the Torrington Employment Center to determine eligibi= lity for other services. I give = my consent for the City of Torrington to gi= ve information contained in this application to the <= st1:PlaceName w:st=3D"on">Torrington Employ= ment Center.

I hereby acknowledge that I have read and understand the above statement.

SIGNATURE:&= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; DATE: = ; &n= bsp; = ; &n= bsp;

Release of Information

To Whom it may Con= cern:

I hereby authori= ze any representative of the Torrington Police Department bearing this release to obtain information from your files or other sources pertaining to my person= al background including, but not limited to, academic, athletic, achievement, attendance, personal history, disciplinary action, medical, credit, or any other records you may have regarding me.&n= bsp; I hereby direct you to release such information upon the request of = the bearer. This release is execu= ted with the full knowledge and understanding that the information is for the official use of the City of To= rrington. Consent is granted for the City of= Torrington to fur= nish such information as is described above to third parties in the course of the Torrington Police Department fulfilling its official responsibilities with = regard to my application for employment. I hereby release you, the institution or establishment that you represent including its officers, employees, and related personnel, both individually= and collectively, from any and all liability for damages of whatever kind that = may at any time result to me, my heirs, family or associates because of complia= nce with this authorization and request to release information, or any attempt = to comply with it. Should there = by any question as to the validity of this release, you may contact me as indicated below.

Name: = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp;

Current Address: = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Telephone: &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Signature: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Date: &= nbsp; &nbs= p;

Subscribed and sworn to in = my presence, this <= span style=3D'mso-spacerun:yes'> day of = , 20 = .

Notary Public &= nbsp; &nbs= p; &= nbsp; &nbs= p;