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Town of Maiden

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					                 Town of Maiden                    “A Town with a Future”

                                             Application for Employment

                                                           Town Hall
                                                     113 West Main Street
                                                  Maiden, North Carolina 28650
                                                        (828) 428-5000

                                              An Equal Opportunity Employer

                                               PRINT AND FILL OUT

                                     GENERAL APPLICANT INFORMATION
                                      Please Read Carefully before completing this Application

   1.   Applications must be completed before consideration for employment. Some specific areas to review for completion are:
        specific title of position applied for, signature, complete address, correct phone number, either home or cell; and you may
        include an e-mail address, and work history. Applications are considered incomplete with an incomplete work history. It is
        unacceptable to indicate “See Resume” or some other direction to another or attached document. Resumes will not be accepted
        in lieu of an application, except, when specifically indicated or requested in an advertisement.

   2.   Only positions currently advertised may be specified on the application. Applicants (including current Town employees) must
        submit a separate application for each posted position.

   3.   Special attention should be given to the deadline date. Any application received after or not postmarked by the deadline date
        will not be reviewed for the current position.

   4.   All applications received are screened for minimum qualifications and the applications meeting minimum qualifications are
        referred to the departments. Departments interview applicants and select the person who best fits the needs of the department,
        subject to the approval of the Town Manager.

                       5.   A copy of your social security card and driver’s license must be attached.

                                                     APPLICANT RECORD
                                                      MUST BE COMPLETED

Date:                                                           Position Title:

Name:                                                           Address:

Telephone: (home)_____________________                          Email address:
Social Security Number: __________-_____-__________ (required for employment)
                                                    APPLICATION FOR EMPLOYMENT
                                                          TOWN OF MAIDEN

NAME: LAST, FIRST MIDDLE                                                      TITLE OF POSITION APPLIED FOR:

ADDRESS:                                                                      RATE OF PAY EXPECTED:

                                                                                             Are you at least 18 years of age?
   WEEKEND WORK                                                                                          Yes                No
   SHIFTS OTHER THAN 8-5                                                                        Date of Birth: __/___/_____
            specify days ______ and hours______ for part-time.



Are you a US Citizen?                                                                                                              Yes    No
If not, are you eligible for permanent full time employment in the United States?                                                  Yes    No
Have you worked for the Town of Maiden before?                                                                                     Yes    No
Are you related by blood our marriage to any person now working for the                                      Yes       No
Town of Maiden?
      (If Yes, give name, relationship and department employed in.)           __________________       __________ ______________
                                                                              NAME                     RELATIONSHIP   DEPARTMENT

Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean        Yes        No
that you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the job for which
you are applying.) If yes, attach explanation on an additional sheet.

                                                 The Town of Maiden is an Equal Opportunity Employer
        EDUCATION                     1    2   3    4    5     6    7     8   9    10    11    12   GED      COLLEGE    1   2      3   4
                                  GRADUATE SCHOOL         1    2     3    4

       SCHOOLS                      NAME AND LOCATION                             GRADUATE                   DEGREE                        MAJOR
      High School                                                                  Yes        No

   College/University                                                              Yes        No

  Graduate/Professional                                                            Yes        No

   Business, Trade, or                                                             Yes        No

Typing _______ WPM                                  Do you have a driver’s license?                       Heavy Equipment you can operate:
Shorthand _______WPM
Computer Applications:                                        Yes        No                               Truck/Dump Truck    Yes      No
   Word     Excel    Power point                                                                          Backhoe        Yes     No
   GIS     ICS Accounting                           State ___ Number____________________________          Front End Loader Yes      No
                                                    Expiration Date ___________                                             Other
             MS Front Page    Other
                                                               License Class       A     B     C

                                                                    WORK HISTORY
       List the jobs that you have held for the last ten (10) years beginning with your last or present employer. Include any part-time jobs,
    volunteer positions, military service, and /or periods of unemployment in the proper sequence. Failure to give complete information may
                    result in rejection of your application. If more space is needed, use additional sheets in the format below.

CURRENT OR LAST EMPLOYER:                           ADDRESS                                               PHONE NUMBER:

JOB TITLE:                                          SUPERVISOR NAME:                                      No. SUPERVISED BY YOU:

DATES EMPLOYED:                                     SALARY HISTORY:                                       REASON FOR LEAVING:

             FROM__________   TO____________        ___________ BEGINNING
                                                     ___________ENDING OR LAST
FULL TIME _____      YEARS         MONTHS               DUTIES                                            IF PART-TIME, NUMBER OF HOURS WORKED PER

PART TIME _____      YEARS         MONTHS

CURRENT OR LAST EMPLOYER:                           ADDRESS                                               PHONE NUMBER:

JOB TITLE:                                          SUPERVISOR NAME:                                      No. SUPERVISED BY YOU:

DATES EMPLOYED:                                     SALARY HISTORY:                                       REASON FOR LEAVING:

             FROM__________   TO____________        ___________ BEGINNING
                                                     ___________ENDING OR LAST
FULL TIME _____      YEARS         MONTHS               DUTIES                                            IF PART-TIME, NUMBER OF HOURS WORKED PER

PART TIME _____      YEARS         MONTHS

CURRENT OR LAST EMPLOYER:                           ADDRESS                                               PHONE NUMBER:

JOB TITLE:                                          SUPERVISOR NAME:                                      No. SUPERVISED BY YOU:

DATES EMPLOYED:                                     SALARY HISTORY:                                       REASON FOR LEAVING:

             FROM__________   TO____________        ___________ BEGINNING
                                                     ___________ENDING OR LAST
FULL TIME _____      YEARS         MONTHS               DUTIES                                            IF PART-TIME, NUMBER OF HOURS WORKED PER

PART TIME _____      YEARS         MONTHS
May we Contact the employers listed above? Yes___ No___.
If not, indicate which employers you do not wish us to contact________________________________________________________________________

                                                             PERSONAL REFERENCES
List three persons who are not related to you and who have definite knowledge of your qualifications and fitness for the position you are applying. Do not
                                                   repeat names of supervisors listed in Work History.

               NAME and OCCUPATION                                             ADDRESS                                         TELEPHONE NUMBER

                                                                 MILITARY SERVICE

Were you ever in the Armed Forces of the United States, or any other military organization?                                      Yes           No

What is your service number? ________________________________

What was the highest rank that you held? ________________

What was the date and location of your first entrance into active duty? _______________________________

          BRANCH                  UNIT/COMPANY/SHIP                         LOCATION                             FROM: MO/YR                TO: MO/YR

What was the date and location of your last discharge from active duty? ____________________________________

Location: __________

Was your last discharge honorable?                    Yes              No

If No, was it characterized as: Bad Conduct    Yes                                No
                   Dishonorable   Yes       No

                                                EMERGENCY CONTACT INFORMATION

NAME                                                  HOME PHONE                            WORK PHONE                         CELL PHONE

ADDRESS                                               CITY                                  STATE                              ZIP

I certify that all of the statements made in this application are true and any attached documents are true, complete, accurate, and correct to the best of my
knowledge and belief and are made in good faith. I understand that false or misleading information or omission may be grounds for rejection of my
application and dismissal if I am employed.

                                                     Signature of Applicant (unsigned applications will not be signed)
                                      DO NOT WRITE IN THE BLOCKS BELOW

Interviewed by:                                                              Date:


                        Rate knowledge, skills, and abilities 0-5 with 0 being the lowest and 5 being the highest
Knowledge                                   Skills                                            Abilities
HIRED:                                      DEPARTMENT:                                       POSITION:
                  Yes   No
SALARY:                                                     START DATE:


Department Head                            Date                  Town Manager                        Date
                   Town of Maiden
                           CONSENT AND AUTHORIZATION

                   Read Carefully and Completely Before Signing

 I have applied for employment with the Town of Maiden and stated I currently/previously
am/was employed by you. My signature below authorizes you to release the contents of my
employment record with your organization, regardless of the content of the record.

 I further consent to allow the Town of Maiden to obtain any and all information concerning
my current/former employment with you or your organization. This includes my job
performance appraisals/evaluations, wage history, disciplinary action(s) if any, and all other
matters pertaining to my employment with you or your organization required in connection
with my application for employment with the Town of Maiden. This form may be photocopied
or reproduced as a facsimile after affixing my signature and those copies are to serve as a true
and accurate copy of this original document, giving the bearer the same rights and authority
as the original document, signed in ink by me and duly witnessed.
Signature of Applicant___________________________________         Date____________________

Witness_______________________________________________            Date___________________
                 Town of Maiden


I hereby authorize any investigator or duly accredited representative of the Town of
Maiden bearing this release, or a copy thereof to obtain any information from schools,
employers, criminal justice agencies, retail credit associations, or individuals, relating
and relevant to my activities. This information may include but is not limited to,
academics, achievement, performance, attendance, personal history, credit rating, and
disciplinary/arrest/conviction records. I understand that the information released is for
official use by the Town of Maiden.

I hereby release any individual, including record custodians, from any and all liability
for damages of whatever kind or nature which may at any time result to me on account
of compliance, or any attempts to comply with this authorization. Should there be any
questions as to the validity of this release, you may contact me as indicated below:

____________________________ ______________________________
Full Name (Printed)    Signature (full name)

___________________________________________________ _________________
Current Address              Date

Telephone Number
                              Town of Maiden
                                     AN EQUAL OPPORTUNITY EMPLOYER
The Town of Maiden will prohibit discrimination on the basis of race, creed, color, religion,
sex, national origin, physical or mental challenge, age, or any other factor which cannot be
lawfully used as the basis for an employment decision.

Federal laws and regulations require employers to monitor and report the status of their equal
employment opportunity programs on a continuing basis. Therefore, we are asking you to
complete the information below. This information will be maintained only for the purpose of
monitoring and reporting compliance in accordance with applicable laws and regulations as
well as to insure compliance with Town policies and procedures and will not be used for any
other purpose.

If you are a veteran, or are physically or mentally challenged, you are invited to volunteer this
information. The purpose is to provide information regarding proper placement and
appropriate accommodation to enable you to perform this job in a proper and safe manner.
This information will be treated as confidential. Failure to provide this information will not
jeopardize or adversely affect any consideration you may receive for employment.

                                               RESEARCH INFORMATION
DATE OF BIRTH:                        ARE YOU A VETERAN?                          SEX:                                 ARE YOU CLAIMING HANDICAP

                                                   Yes          No                             Male    Female
                                                                                                                                         Yes      No
                      ETHNICITY:                    PLEASE CHECK ALL THAT APPLY:                           HOW DID YOU LEARN ABOUT THIS

                                                    ___Visual Impairment                                   ___Town’s posted notice
  __American Indian/Alaskan Native                  __Hearing Impairment                                   ___Newspaper/Journal Ad
  __Asian/Pacific Islander                          ___Cardiovascular Disorder                             __ Employment Security Commission
  __Black                                           ___Emotional/Mental Disorder                           ___Friend
  __Hispanic/Latino                                 ___Nervous System/Neurological Disorder                ___City Employee
  __White                                           ___Respiratory Impairment                              ___School Counselor/Placement Office
  __Other                                           ___Loss or Impairment of Limb (s)                     __ Other
                                                    ___Disabling Diseases (Diabetes, Arthritis, etc)
                  Town of Maiden
                           STATEMENT OF DRUG POLICY

I ____________________________ do hereby state and say by affixing my signature that I understand
that the Town of Maiden has a drug policy and that an applicant who is considered for any position in
the employ with the Town will undergo a mandatory drug screen prior to being hired. I further signify
that I understand that as part of that policy, random drug testing may and will occur as a condition to
continued employment.

____________________________ ______________________________
Full Name (Printed)       Signature (full name)

___________________________________________________ _________________
Current Address              Date

Telephone Number