City of Burien, Washington

 

 

 

 

15811 Ambaum Blvd. SW, Suite C                                                Phone (206) 241-4647

Burien, WA  98166-3066                                                               Fax (206) 248-5539

 

       Employment Application

The City of Burien is an Equal Opportunity Employer

 

POSITION APPLIED FOR

 

 

Thank you for your interest in the City of Burien as an employer.  Only final candidates for posted openings will

be contacted personally by the City.

 

GENERAL INFORMATION

 

Name (last, first, middle initial)                                                                                                                              Social Security No. (Optional)

 

 

Street Address                                                                                                                                                                       City, State, Zip

 

 

Home Phone No.                                                                                                  Work Phone No.                                                                                       Message Phone No.

 

 

Are you authorized to work in the United States?   Proof of Authorization will be required post hire.

Yes   No                                          

TRAINING AND EDUCATION

Circle highest grade completed:           8                  9                  10             11               12             GED

 

Colleges/other training

 

Major/subject

 

Degree/certificates

 

 

 

 

 

 

ADDITIONAL SKILLS  Describe skills relevant to the job for which you are applying

SKILL

TYPE OF EXPERIENCE

LEVEL OF EXPERTISE

Office equipment, computers, software (typing speed, programs, etc.)

 

 

Technical skills, professional licenses

 

 

Heavy equipment, machinery

 

 

Other

 

 

Can you perform the essential functions of the job with or without reasonable accommodation?      Yes                No  

BACKGROUND INFORMATION

each case is considered separately based on job duties and performance areas

Do you have a valid Washington State Driver's License?                   Yes              No                 Other State _____________

(If position applied for involves driving), have you been convicted, pleaded to no contention or paid a fine for any traffic violations in the past three (3) years?                         Yes              No           If yes please explain:

 

Have you been convicted of a felony or served time in prison within the last ten (10) years?    Yes             No

Conviction will not necessarily bar you from employment.  If yes, please explain:

 

 

How/where did you hear about the position for which you are applying?  (Check one)

 

______ Friend or relative

 

______ City employee

 

______ Employment Security

______ Newspaper ad

Which?__________________________

______ City job bulletin

______ City job hotline

______ Other please specify  ______________________________

 

 

 

Please turn over and complete page 2

 

 

 

EMPLOYMENT HISTORY

 

Beginning with your present or most recent employment, list your employment history.  Include self-employment, military service, volunteer experience and periods of unemployment.  The following sections MUST be completed even if a resume is submitted.

 

Employer

Employed from:

To:

 

Address:

Supervisor

 

Phone

Hours worked/week

Starting salary

 

Position

Last salary

 

Primary duties

 

 

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

 

Reason for leaving

 

Employer

Employed from:

To:

 

Address:

Supervisor

 

Phone

Hours worked/week

Starting salary

 

Position

Last salary

 

Primary duties

 

 

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

 

Reason for leaving

 

Employer

Employed from:

To:

 

Address:

Supervisor

 

Phone

Hours worked/week

Starting salary

 

Position

Last salary

 

Primary duties

 

 

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

 

Reason for leaving

 

Employer

Employed from:

To:

 

Address:

Supervisor

 

Phone

Hours worked/week

Starting salary

 

Position

Last salary

 

Primary duties

 

 

Number of employees

supervised by you

May we contact this employer

Supervisor's

phone

 

Reason for leaving

PROFESSIONAL REFERENCES

Please list below any people in addition to supervisors listed above who can responsibly evaluate your work performance

 

 

 

 

Name

Place of employment/title

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

It is understood and agreed that the foregoing is true to the best of my knowledge, and that my falsification of this application will be grounds for elimination from further consideration or, if employed by the City of Burien, for dismissal.  I authorize the City of Burien to solicit information regarding my character, general reputation, credit, previous employment, and similar background information, and to contact any and all references I have given on my application.  I release all parties and persons connected with any such request for information from all claims, liabilities, and damages that may arise out of the furnishing of such information.  If employed, I release the City of Burien from any liability for future references it may provide regarding my work history at the firm.

 

I understand that employment  with the Employer is “at-will”, which means that either the City or I can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute.  All employment is continued on that basis.  I understand that no supervisor, manager or executive of the Employer, other than the City Manager has any authority to alter the foregoing.

 

Applicant's signature____________________________________________________ Date____________________________