City of St. Charles
Human Resources Department
2 East Main Street
St. Charles, IL 60174

Application for Employment

It is the policy of the City of St. Charles to provide all persons equal employment opportunities. This policy prohibits discrimination because of race, color, religion, national origin, ancestry, age, sex, sexual orientation, marital status, or physical or mental impairments unrelated to ability to perform essential job functions. We welcome you as an applicant for employment.

Once this application has been received by the City, all information contained in or connected with this application will be considered personal and confidential and used only in conjunction with your possible employment by the City of St. Charles. The City cannot guarantee complete security of the application during transmission of this form via email.

Please furnish us with COMPLETE information as outlined in this application. Incomplete applications will NOT be considered. You are encouraged to attach any additional information, which you believe relates to your qualifications for the position for which you are applying.

Position(s) Applied For:

Date of Application:

Personal Information

Last Name	First Name	Middle Name
Street Address	City	State	Zip-code
Telephone Number	Email Address
Date available for work:

Work Type

Please indicate the type of employment desired.
Full-Time	Part-Time	Temporary	Summer	Educational Co-op	Internship

Referral Source

Please indicate how you heard about the job you are applying for.
	Community Service Line
	Walk-In
	Employment Agency Name
	Relative's Name
	Newspaper Name
	Periodical Name
	Website
	Other Source

If necessary, best time to call you at home is AM PM

Have you filed an application here before? Yes No
If yes, give position applied for:

Have you ever been employed here before? Yes No
If yes, give dates. From: To:

Is any of your employment data under a different name? Yes No
If yes, state name:

Are you legally eligible for employment in this country? Yes No
(Proof of U.S. Citizenship or Immigration status will be required upon employment.)

Are you on lay-off subject to recall? Yes No

Have you been convicted of a felony? Yes No
(Such conviction may be relevant if job related, but does not bar you from employment.)
If Yes, please explain:

Do you have a valid driver's license? Yes No

Do you have a valid Commercial Driver's License (CDL)? Yes No

Education

Please indicate the last three schools that you have attended.
School Name	Years Completed	Degree or Diploma	GPA/Class Rank	Major	Minor

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name	Telephone Number	Years Known	Type
			Business School Personal
			Business School Personal
			Business School Personal

Employment History

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

Employer #1
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #2
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #3
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #4
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Comments:

Including an explanation of any gaps in employment.

Skills and Qualifications:

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work for the City.

Please Read Carefully

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that falsified statements or omission of facts on this application shall be considered sufficient cause for termination of employment or cancellation of application.

I understand and agree that the City of St. Charles is hereby authorized to make inquiries concerning my character, employment record and other matters concerning my possible employment. I further understand that such inquiries will include checking police records for convictions. I hereby release from liability the employer and its representative for seeking such information and all other persons, corporations or organizations for furnishing such information. I understand that I may request reasonable accommodation if needed, due to disability, in order to participate in the overall application process.

This application is current for 3 months from the date it was submitted. At the conclusion of this time, if I have not heard from the City and still wish to be considered for employment, it will be necessary to complete a new application.

I understand the filing of this application or participation in an interview in no way constitutes an employment contract between the City of St. Charles and me. I acknowledge the right of the City of St. Charles to make changes in policy and benefits where not specified or covered by contract without notice.

I understand that any offer of employment is conditional upon the successful completion of a background check, drug screen and/or physical exam. Should I become employed, I agree to conform to all rules and regulations of the City of St. Charles. I understand that I have the right to terminate my employment at any time and the City of St. Charles retains the same right.

Signature

I have read the statements above and fully understand and agree. This application will not be accepted unless this box is checked.
Signature of Applicant:	Date: