City of Lacy Lakeview Employment Application

City of Lacy Lakeview
P.O. Drawer 154549  Waco, TX 76715-4549  (254) 799-2458
Employment Application
We welcome and appreciate your interest in employment with the City of Lacy Lakeview. We are an equal opportunity employer. No question on this application is intended to secure information for discriminatory purposes.

Applicants are required to submit accurate, complete and truthful information in response to questions on this application, on a resume, and other information provided, including post-offer medical history information and information related to the post-offer drug test provided by the City’s designated physician. Failure to do so will be grounds for rejection of this application. Applicants must provide supplemental written information where necessary to accurately and completely respond to questions. If the applicant selected for this position is not a City employee, his/her employment history will be checked for a minimum of two previous employers, or for the past ten years, whichever is greater. If the applicant is a City employee, a review of the employee’s personnel file and a reference check of the immediate supervisor will be reviewed.

This form is part of the examination process. Before completing the application, consider the duties of the job with or without reasonable accommodation and minimum qualifications for the specific job for which you are applying. You must meet the minimum qualifications of the position to be considered.

The City of Lacy Lakeview reserves the right to disqualify any application which is incomplete. This application may be completed at your convenience; however, failure to provide required documents by the published recruitment deadline may result in disqualification. All applicants are required to complete an application form prior to interviewing for a position. (Resumes will not be accepted in lieu of completing the application but may be attached
Please complete the following the information
Position Applied For
Today’s Date

MonthDayYear
Date
Name

First NameMiddle InitialLast Name
YesNo
If yes, provide the name
LAST NAME
First Name
Middle Initial
Additional Names

First NameMiddle InitialLast Name
YesNo
If yes, provide below: Position
Date

MonthDayYear
Date
Contact Information
Address
Apt. No.
City
State
Zip Code
Telephone Number (Home)
Format: (000) 000-0000.
Telephone Number (Cell)
Format: (000) 000-0000.
E-mail
example@example.com
Education History
YesNo
School Name/City
YesNo
Test Center Name/City
Additional Academic/Vocational/Business Education

Rows	Name of School/City	Areas of Study	Trade School/College Se m. Hrs	Type of Certificate Received	Type of Degree Received

Current Licenses / Certifications / Registrations
Submit a copy of the required certification with this application.
Type
Number
Agency/State Issuing
Expiration Date

MonthDayYear
Date
Type
Number
Agency/State Issuing
Expiration Date

MonthDayYear
Date
YesNo
Driver's License Information
Driver's LicenseID
YesNo
State Issued
Number
Expiration Date

MonthDayYear
Date
Type/Class
*Please list and give date(s) or every morning violation and/or traffic accident in the last threee (3) years.
Incident-1
Location
Expiration Date

MonthDayYear
Date
Incident (2)
Location
Expiration Date

MonthDayYear
Date
Incident (3)
Location
Expiration Date

MonthDayYear
Date
Employment History
List all employment for at least the past 10 years or for your last 2 employers, whichever is greater. Begin with your present position and work back. Explain any gaps in employment. Attach additional sheets as needed. OPTIONAL: Additional information on your training and/or experience which relates to the job opening may be provided on attached sheets.
YesNo
From (Month)
From (Year)
To (Month)
To (Year)
Job Title
Employer
Address
Supervisor Name
Employer Phone
Format: (000) 000-0000.
Supervisor Phone
Format: (000) 000-0000.
Job Duties
Reason for Leaving
Salary (Annual or Hourly)
Job #2
YesNo
From (Month)
From (Year)
To (Month)
To (Year)
Job Title
Employer
Address
Supervisor
Employer Phone
Format: (000) 000-0000.
Supervisor Phone
Format: (000) 000-0000.
Job Duties
Reason for Leaving
Salary (Annual or Salary)
Job #3
YesNo
From (Month)
From (Year)
To (Month)
To (Year)
Job Title
Employer
Address
Supervisor
Employer Phone
Format: (000) 000-0000.
Supervisor Phone
Format: (000) 000-0000.
Job Duties
Reason for Leaving
Salary
Please answer yes or no to the following questions.
YesNo
If yes, provide the Year
YEAR
Department
DEPARTMENT WORKED FOR
YesNo
If yes, complete the following: Department
DEPARTMENT
Name
Relationship
YesNo
If yes, state name and address of employer and explain the circumstances.
YesNo
If yes, state name and address of employer and explain the circumstances.
YesNo
If yes, state name and address of employer and explain the circumstances.
YesNo
If yes, state name and address of employer and explain the circumstances.
Personal References
Please do not list former employers or relatives. Those listed should be familiar with your qualifications for employment.

Rows	Name and Occupation:	City/ State of Residence	Phone Number
Reference 1
Reference 2
Reference 3

Conviction Record
Failure to answer the following question will disqualify you from further consideration of your application.
YesNo
If yes, complete Application Attachment I in detail. A conviction will not automatically exclude you from consideration for employment. The nature, seriousness, number of offenses, length of time since offenses, your work record with other employers after the offenses, and the nature of the position shall be considered.
READ CAREFULLY BEFORE SIGNING
I certify that all information in this application is true and correct. I understand and agree that any false information, misrepresentation, or concealment of fact is sufficient grounds for either my immediate discharge without recourse, or refusa l of employment by the City of Lacy Lakeview.

I understand and agree that all information in this application may be verified by the City of Lacy Lakeview. I also understand that any employment is subject to a satisfactory check of references, and that once a contingent offer of employment is made, I must satisfactorily pass a post job offer physical, which will include drug and alcohol tests.

I authorize all individuals and organizations named or referenced to in this application, or given otherwise by me as references, to give the City of Lacy Lakeview all information relative to my employment, work habits, and character. I authorize the City of Lacy Lakeview to verify and investigate the status of my driver’s license and to conduct any background check it deems necessary, including review of criminal history records. I hereby release the City, and any individual who provides or obtains information pursuant to this authorization, from any and all liability for damages of any kind that may result to me on account of compliance, or attempts to comply with this authorization. I am also aware that my application is subject to the Texas Open Records Law and may be released as a public document.

I understand that this is not an employment agreement between the City of Lacy Lakeview and the applicant.
Signature
Date

MonthDayYear
Date
NOTICE OF CONDITIONS OF EMPLOYMENT
I understand that as a condition of employment with the City of Lacy Lakeview, I will be required to pass a drug test and agree to abide by the City’s Alcohol and Drug Policy.
Signature
Date

MonthDayYear
Date
Please upload any additional documents that you would like to add to this application. (Ex. resume, certifications, credentials, etc)

Cancelof
Application Attachment I
Failure to fully complete this form shall result in your disqualification in the applicant process, or if hired, termination. To provide information on additional offenses, please add additional sheets as required. If it does not apply to you us N/A.

The information sought on this form will be used solely for the purpose of assisting the City of Lacy Lakeview in conducting a criminal history check. More information may be necessary to complete the investigation and failure to provide such information on request will disqualify you from further consideration for employment. Please complete this section if you have ever been convicted of, plead guilty to, no contest to, received probation, deferred adjudication, or been placed on any form of diversion for any criminal offense (misdemeanor and/or felony) in any court other than Juvenile Court. Your criminal record will be considered by the City of Lacy Lakeview only in relation to the job for which you are applying. The nature, seriousness, number of offenses, length of time since offenses, your work record with other employers after the offenses, and the nature of the position for which you are applying shall be considered.
Print Full Name
Date

MonthDayYear
Date
Sentence
Probation, deferred adjudication or other form of pre-trial diversionJailOtherFine
Criminal Offense
Location
City
State
Date

MonthDayYear
Date
Brief Explanation
*Use next page to include additional information.
Reporting Requirements
Parole/Probation Officer Name
Address
Telephone No.
Format: (000) 000-0000.
If on Probation, ending date

MonthDayYear
Date
Additional Information on Sentence
Application Attachment II
Applicant Demographics Report
COMPLETION OF THIS FORM IS VOLUNTARY
The City of Lacy Lakeview is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the City of Lacy Lakeview invites applicants to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Information provided on this form is not part of the hiring process and is not considered by those involved in the hiring process. Qualified applicants and employees are considered without regard to race, color, religion, sex, national origin, age, marital status, or disability.
Name
MaleFemale
Date of Birth

MonthDayYear
Date
Position Applied for: (Must indicate specific job title)
EEO Classification
Specific Instructions: The categories below are designed to identify your basic racial and national origin category. Place a “check” next to the appropriate category.
WhiteNative Hawaiian or Other Pacific IslanderBlack or African AmericanHispanic or LatinoTwo or more races, excluding Hispanic or LatinoAmerican Indian or Alaskan Native (Not Hispanic or Latino)Asian
Employment Eligibility Verification
In what country were you born?
YesNo
Driver’s License and Social Security CardU.S. Passport showing U.S. CitizenshipCertificate of U.S. Citizenship or NaturalizationOther (Specify)”Green Card
Source of Information About Applying
Current EmployeeTexas Employment CommissionNewspaperPosted job announcementFriendProfessional publicationWalk-InWebsite
Should be Empty:

City of Lacy Lakeview

Employment Application

Please complete the following the information

Education History

Additional Academic/Vocational/Business Education

Current Licenses / Certifications / Registrations

Driver's License Information

Employment History

Job #2

Job #3

Please answer yes or no to the following questions.

Personal References

Please do not list former employers or relatives. Those listed should be familiar with your qualifications for employment.

Conviction Record

READ CAREFULLY BEFORE SIGNING

NOTICE OF CONDITIONS OF EMPLOYMENT

Application Attachment I

Sentence

Location

Reporting Requirements

Application Attachment IIApplicant Demographics Report

COMPLETION OF THIS FORM IS VOLUNTARY

EEO Classification

Employment Eligibility Verification

Source of Information About Applying

Application Attachment II
Applicant Demographics Report