CITY OF DUNN

Application for Employment

An Equal Opportunity Employer

1. Position (s) applied for Date

2. Name 3. Social Security Number

__________ ________ ____________

(Last) (First) (Middle)

4. Present Mailing Address

(Street & No. or RFD) (City) (County) (State) (Zip)

Permanent Mailing Address

(Street & No. or RFD) (City) (County) (State) (Zip)

Telephone: Home_____________ Business _______________ if none, where can you be reached by telephone?______________

5. MILITARY SERVICE:
(A) Are you a veteran?
Yes
No
(B) Are you a widow or a veteran,
or wife of a disabled veteran?
Yes
No
(C) Date of entry into active service: _____ _____ ______
(D) Date of separation from active service: _____ _____ ______

INDICATE ANSWER BY PLACING AN “X” IN PROPER COLUMN

Yes No Yes No
6. May inquiry be made of your present employer 8. Have you filed an Application for
Regarding your qualifications? employment
With the City of Dunn within the past year?
7. Have you ever been convicted of a felony? 9. Are you related by blood or marriage to any
Person now employed by the City?
If yes, give name and relationship in Space No. 10.

10. Use this space to explain an answer for above questions. (Number answers to correspond to questions above; attach additional sheet if needed)

11. References: If you wish to list references, please complete the following:

(A) Name_______________________________ Address_______________________________________ Telephone #__________________

(B) Name_______________________________ Address_______________________________________ Telephone #__________________

(C) Name_______________________________ Address_______________________________________ Telephone #__________________

All Applications Will Be Kept on File For A Period of 2 Years.

 12. EDUCATION – Give your complete educational history below:
Name of Name Location Ending Date Circle Highest School Year Completed
Educational Mo_____ Yr______ 1 2 3 4 5 6 7 8 9 10 11 12
Institution
13 A. Did you either graduate from high school or pass the High School Equivalency Test?
Yes
No
13 B Have you received your GED?
Yes
No
Education Name and Location Circle Did Degree or Major
Beyond Number Years Credit You Diploma and Subject
High School Completed Hours Graduate? Year Received
College
or 1 2 3 4
University
Graduate
or 1 2 3 4
Professional
Other
Education 1 2 3 4
Internship, etc.
14. List Fields of work which you are licensed, registered or certified.

Registration___________________________________________________ State__________________________ No.________________________

Registration___________________________________________________ State__________________________ No.________________________

15. Clerical Skills: Typing ____________ wpm Shorthand Speed _______________ wpm Other:________________________

16. If the position applied for calls for specific courses, indicate courses and credit received.

17. Employment Record – Answer questions for each period of employment. Include military service and previous employment with the City of Dunn.
Failure to give complete information may result in rejection of your application. Begin with your present or last position. If more spaces is needed,
use a continuation sheet.

Starting Last
A. Title of present or last position__________________________ Salary ________________________ Salary_________________________
Date Employed Name and title of Supervisor___________________________________________ No. employees supervised by you____________
Employer________________________________________________ Address___________________________________________
Date Separated Duties ________________________________________________________________________________
Full-time Years Months _____________________________________________________________________________________
_____________________________________________________________________________________
Part-time Years Month
_____________________________________________________________________________________
_____________________________________________________________________________________
If part-time, number of
hours worked per week Reason for leaving ___________________________________________________________________________________________

Starting Last
B. Title of present or last position__________________________ Salary ________________________ Salary_________________________
Date Employed Name and title of Supervisor___________________________________________ No. employees supervised by you____________
Employer________________________________________________ Address___________________________________________
Date Separated Duties ________________________________________________________________________________
Full-time Years Months _____________________________________________________________________________________
_____________________________________________________________________________________
Part-time Years Month
_____________________________________________________________________________________
_____________________________________________________________________________________
If part-time, number of
hours worked per week Reason for leaving ___________________________________________________________________________________________
 Starting Last
C. Title of present or last position__________________________ Salary ________________________ Salary_________________________
Date Employed Name and title of Supervisor___________________________________________ No. employees supervised by you____________
Employer________________________________________________ Address___________________________________________
Date Separated Duties ________________________________________________________________________________
Full-time Years Months _____________________________________________________________________________________
_____________________________________________________________________________________
Part-time Years Month
_____________________________________________________________________________________
_____________________________________________________________________________________
If part-time, number of
hours worked per week Reason for leaving ___________________________________________________________________________________________

Starting Last
D. Title of present or last position__________________________ Salary ________________________ Salary_________________________
Date Employed Name and title of Supervisor___________________________________________ No. employees supervised by you____________
Employer________________________________________________ Address___________________________________________
Date Separated Duties ________________________________________________________________________________
Full-time Years Months _____________________________________________________________________________________
_____________________________________________________________________________________
Part-time Years Month
_____________________________________________________________________________________
_____________________________________________________________________________________
If part-time, number of
hours worked per week Reason for leaving ___________________________________________________________________________________________

Are you a citizen of the United States?
Yes
No

If not, do you have a legal right to work or remain in the United States?
Yes
No

Can you, after employment, submit certification or your legal right to work in the United States?
Yes
No

Are you 18 years of age or older?
Yes
No

List the name and phone number of an individual to be contacted in case of an emergency accident.
__________________________________________________________________________________________
_____________________________________________________________________________

I certify that I have given true accurate and complete information on this form to the best of my knowledge. In the event
confirmation is needed in connection with my work, I authorize educational institutions, associations, registrations and
licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation
of all statements made in this application and understand that false information or documentation, or a failure to disclose
relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed,
and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent
disclosures are given to meet position qualifications.
(Authority: G.S. 126-30, G.S. 14-122.1)

________________________________________________________________________________________ __________________________________________
Signature of Applicant (unsigned applications will not be processed) Date

Employment Application/Revised 10/16/06