AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY - Territories - AS GU MP PR UM VI - Armed Forces - AA AP AE

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Last Name *

Phone #1 *

Are any of your relatives employed by the City of Hopkinsville? *

ZIP *

City *

Temporary/Seasonal

State *

Phone #2

Previous/Alternate Names

Are you a US Citizen, permanent resident or otherwise legally authorized to accept employment with the City of Hopkinsville? *

If yes, list hours and/or days:

Availability

If yes, list position(s):

Have you previously been employed by the City of Hopkinsville? *

Employment Eligibility

Email

If yes, list department and relationship:

Full Time

Address *

First Name *

Part Time

Any offer of employment by the City of Hopkinsville will be conditional upon your providing documentation required by law as evidence of personal identity and your authorization to work in the United States.

Are there any hours and/or days you cannot or will not work? *

Do you have an email? *

Are you over 18 years of age? *

Yes No

Active Duty Start Date:

If yes, list Branch of Service:

Active Duty End Date:

Have you served in the US Armed Forces? *

Date of Final Discharge:

Enter any previous education and training experience below. Click the "Add new record" button, enter information and click "Save" for each. A minimum of one previous education or training must be listed below. Please do not put "see resume".

Yes No

Will Will not

Based on the job description of the position for which you are applying you: *

need reasonable accommodations in order to perform the essential functions of this job.

Describe any accommodations you will need to adequately perform the essential functions of the position.

If yes, are there any you wish to exclude?

List any special skills, experience, training, licenses, certifications you have that are relevant to the position for which you are applying, or any additional information that we should consider.

May we contact these companies/institutions for references? *

List all employers starting with the most recent. Click the "Add new record" button, enter information and click "Save" for each. *

Copy and Paste, or Type out your resume into the window below.

List at least three people we may contact in reference to your application. Do not include past or present supervisors listed under Employment section. Click the "Add New Record" button, enter the information and click "Save" for each. *

Yes No

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY - Territories - AS GU MP PR UM VI - Armed Forces - AA AP AE

Yes No

A B C

Do you have a valid Driver's License?

Do you have a valid CDL License?

For positions requiring a Driver's License and/or CDL License

Driver's License State

List any equipment operated or other qualifications

CDL Class

CDL License #

Male Female

Hispanic White (Non Hispanic) Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Two or More Races Choose not to self-identify

Yes No

Yes No

Yes No

Yes No

Yes No

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Yes No

I AM A VETERAN WHO SERVED ON ACTIVE DUTY DURING THE WAR OR IN A CAMPAIGN OR EXPEDITION FOR WHICH A CAMPAIGN BADGE HAS BEEN AUTHORIZED.

IMPORTANT—To ALL Applicants: To enable us to meet government reporting regulations, the City of Hopkinsville requests you complete this personal data form. Information will be used solely for government reporting purposes and will be detached and kept separate from your application. Any information you choose to provide will not be considered by the City of Hopkinsville for employment purposes and will be treated as confidential. Your voluntary cooperation is appreciated.

I qualify as a Special Disabled Veteran because I am:

If any of these definitions apply to you, please choose the appropriate choice. If you identify as more than one please choose "Two or More Races".

(A) was discharged or released with other than a dishonorable discharge;

(1) A veteran who is entitled to compensation (or who but for receipt of military retirement pay would be entitled to compensation) under laws administered by the Veterans Administration for disability;

The City of Hopkinsville is asking you to provide this information, because we must submit a statistical report in accordance with the regulations promulgated under 38 U.S.C. Section 2012 and must monitor statistics for the U.S. Government.

(A) which is rated 30% or more,

(1) A person who served more than 180 days of active military, naval or air service, any part of which was during the period August 5, 1964 through May 7, 1975 and who:

Veteran Status

Voluntary Information Only

Gender

(B) which is rated at 10 or 20%, but it has been determined, under Section 1506 of Title 38, U.S.C., that I have a “serious employment handicap;”

Race/Ethnic Category

I AM A VETERAN OF THE VIETNAM ERA

(C) which is service connected and caused me to be released from active duty.

I qualify as a veteran of the Vietnam Era because I am:

I AM A “SPECIAL DISABLED VETERAN”

(B) was discharged or released from active duty because of a service connected disability.

Signature *

I hereby declare the information in the Application for Employment is true, correct and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I authorize the CIty of Hopkinsville to check my background and obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends and acquaintances. This report, if obtained, may include information as to my character, general reputation, personal characteristics and mode of living/ I have the right to make a written request within a reasonable period to receive information about the nature of any investigation.

The City of Hopkinsville is an AT-WILL, EQUAL OPPORTUNITY EMPLOYER and does not discriminate on the basis, of race, sex, color, religion, national origin, age, disability or veteran status in employment opportunities and benefits.