Employment Job Application

Exactly as extracted, unformatted — for checking against the original. The readable version is easier to read.

For Office Use Only
Date Rec’d
Appendix B
Meets Min Quals
Initial Rating Score
Final Rating Score
Town of Centreville
APPLICATION FOR EMPLOYMENT
Date:
Position Applied For:
NAME AND CONTACT INFORMATION
Name:
Last First Middle
Address: City: State: Zip:
Email:
Home Phone: Work Phone: Cell Phone:
Do You Have a Valid Driver’s License? Yes _________ No _______________
License Number: ____________________________ State: ______________ Expiration: _____________
A COPY OF YOUR LICENSE MUST ACCOMPANY THIS APPLICATION.
EDUCATION AND TRAINING
Do you have a high school diploma or GED? Yes No If not, what is the highest grade completed?
Circle Last Graduate Diploma or
Level School Name and Course of Study Year (Yes/No) Degree
Address Completed Rec’d
High 1 2 3 4
School
College 1 2 3 4
Other 1 2 3 4
(Specify)
Please submit a copy of any relevant professional or trade licenses or certificates with this application.

Appendix B
WORK EXPERIENCE
List below, beginning with your most recent position, all of your work experience, including military service and all volunteer activities.
Attach additional 8 ½” x 11” sheets of paper if necessary. If your title or duties changed in the course of your service in any one
organization, indicate such changes clearly, and as separate employment. Please do not submit a resume in lieu of completing this portion of
the application. Be sure that the information included in this section demonstrates that you meet the minimum experience qualifications for
the job for which you are applying.
I hereby give my permission to contact the employers listed below concerning my prior work experience.
Signed
If there is a particular employer(s) you do not wish us to contact, please indicate which one(s).
Job Number 1
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Job Duties:
Reason for leaving:
Job Number 2
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Job Duties:
Reason for leaving:
Job Number 3
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________

Appendix B
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Beginning Weekly Salary: Last Weekly Salary:
Job Duties:
Reason for leaving:
Job Number 4
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Job Duties:
Reason for leaving:
Job Number 5
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Job Duties:
Reason for leaving:
Job Number 6
Name of Employer Employer’s Address (Street, City, State, Zip Code)
Type of Business Supervisor’s Name and Phone Number
Your Job Title Do you supervise Job Titles of those you supervise
other employees?
Yes___No___How
many?________
Dates of Employment (from: Month/Year To Month/Year) Is your position considered full time? Yes______ No______
How many hours do you work per week?
Job Duties:
Reason for leaving:

Appendix B
MILITARY SERVICE RECORD
Were you in the U.S. Armed Forces? Yes No If yes, what branch?
Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for?
PLEASE READ AND SIGN BELOW
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY
APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO
SUBMIT TO OR TAKE A POLYGRAPGH, LIE DETECTOR OR SIMILAR TEST OR
EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY
EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND
SUBJECT TO A FINE NOT TO EXCEED $100.
(The provision above does not apply to applicants for law enforcement positions pursuant to Labor and Employment Article,
Section 3-702 (b) Annotated Code of Maryland.)
The facts set forth in my application for employment are true and complete. I understand that if employed,
false statements on this application shall be considered sufficient cause for dismissal. I further understand
that this application is not and is not intended to be a contract of employment, nor does this application
obligate the employer in any way if the employer decides to employ me. You are hereby authorized to
make any investigation of my personal history, including an investigative consumer report whereby
information is obtained through personal interviews with my neighbors, friends, or others with whom I
am acquainted. This inquiry, if made, may include information as to my character, general reputation,
personal characteristics and mode of living. I understand that I have the right to make a written request
within a reasonable period of time to receive additional, detailed information about the nature and scope
of any such investigative report that is made.
Signature of Applicant
Date
Updated 01/20/2023