property of the City of Port Orchard and will not be returned. Nothing can be added to your application after the announcement period has closed. All statements made on the application are subject to verification.<br><br> Failure to follow these instructions, initial this paragraph and sign this applicatio n will be cause for rejection of the application. Illegible or incomplete applications may be rejected. Exaggerated, false, or misleading statements will be cause for rejection of the application and/or termination of employment.<br><br> My initials at the end of this sentence affirm that I have read and understand these instructions. _____________ PERSONAL INFORMATION LAST NAME FIRST M.I. OTHER NAMES BY WHICH YOU HAVE BEEN KNOWN COMPLETE MAILING ADDRESS RESIDENCE ADDRESS, IF DIFFERENT FROM ABOVE SOCIAL SECURITY NUMBER TELEPHONE NUMBER ( ) ALTERNATE NO.<br><br> WHERE YOU MAY BE REACHED ( ) ARE YOU 18 YEARS OF AGE OR OLDER (21 YEARS OF AGE FOR POLICE APPLICANTS)? YES NO DO YOU HAVE A LEGAL RIGHT TO WORK IN THE UNITED STATES? IF OFFERED EMPLOYMENT YOU WILL BE REQUIRED TO PRESENT EVIDENCE OF YOUR RIGHT TO WORK.<br><br> YES NO HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH THE CITY OF PORT ORCHARD? YES NO HAVE YOU PREVIOUSLY BEEN EMPLOYED BY THE CITY OF PORT ORCHARD? IF YES, COMPLETE THE FOLLOWING INFORMATION: JOB TITLE/DEPARTMENT DATES: FROM TO YES NO LIST ANY RELATIVES OR MEMBERS OF YOUR HOUSEHOLD WHO ARE EMPLOYED BY THE CITY OF PORT ORCHARD.<br><br> NAME JOB TITLE/DEPARTMENT DRIVER 9S LICENSE : If the position for which you are applying will require you to operate a vehicle: (1) You must possess a valid driver 9s license. (2) Any special endorsements must be current and valid. (3) If you are offered employment by the City of Port Orchard, and if your driver 9s license is from another state you will be required as a condition of employment to obtain a valid Washington State Driver 9s License before you can begin work .<br><br> NUMBER STATE EXPIRATION DATE CLASSIFICATION DO YOU AUTHORIZE THE CITY OF PORT ORCHARD TO INVESTIGATE YOUR DRIVING RECORD? IF YES, THE CITY MAY, AT ITS DISCRETION, OBTAIN AN ABSTRACT OF YOUR DRIVING RECORD FROM THE APPLICABLE DEPARTMENT OF DRIVERS LICENSING. YES NO EMPLOYMENT DESIRED POSITION OR TYPE OF WORK FOR WHICH YOU ARE APPLYING: HOW DID YOU LEARN ABOUT THE POSITION FOR WHICH YOU ARE APPLYING?<br><br> DO YOU WISH TO WORK: FULL TIME PART TIME TEMPORARY SUMMER IF PART TIME, SPECIFY DAYS & HRS. PER WEEK WHAT IS YOUR MINIMUM SALARY REQUIREMENT? $ PER DATE AVAILABLE FOR WORK: DO YOU HAVE ANY COMMITMENTS TO ANOTHER EMPLOYER THAT MIGHT AFFECT YOUR EMPLOYMENT WITH US?<br><br> SPECIFY COMMITMENTS YES NO EDUCATION : Educational qualifications are subject to verification. If an offer of employment is made, you may be asked to provide dates of attendance to facilitate verification. DO YOU HAVE A HIGH SCHOOL DIPLOMA OR EQUIVALENT?<br><br> YES NO WHAT POST SECONDARY DEGREE(S) DO YOU HOLD? MAJOR/MINOR DEGREE, FIELD OR PROGRAM OF STUDY NAME AND LOCATION OF COLLEGES OR UNIVERSITIES ATTENDED MILITARY SERVICE DATES OF U.S. MILITARY SERVICE BRANCH OF SERVICE RANK AT SEPARATION FROM TO MO.<br><br> YR. MO. YR.<br><br> (Civil Service Positions ONLY) IF YOU ARE CLAIMING PREFERENCE AS A VETERAN OR DISABLED VETERAN, YOU MUST ATTACH A COPY OF YOUR DD-214 FORM AND/OR YOUR V.A. DISABILITY LETTER AND CLAIM NUMBER VETERAN'S POINTS CLAIMED (CIRCLE 1) 5 10 LIST ANY SPECIALIZED TRAINING RECEIVED IN THE MILITARY OPTIONAL: LIST ANY MEDALS, COMMENDATIONS, OR AWARDS RECEIVED IN THE MILITARY EMPLOYMENT HISTORY MAY WE CONTACT YOUR PRESENT EMPLOYER REGARDING YOUR RECORD OF EMPLOYMENT? (JOB 1) PRESENT OR MOST RECENT JOB COMPANY NAME FROM TO TOTAL TIME ADDRESS MO.<br><br> YR. MO. YR.<br><br> YRS. MOS. TELEPHONE NUMBER YOUR JOB TITLE HOURS PER WEEK SUPERVISOR'S NAME & TITLE STARTING SALARY $ PER REASON FOR LEAVING POSITION LAST SALARY $ PER SPECIFIC DUTIES _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ NUMBER OF EMPLOYEES SUPERVISED (IF APPLICABLE) (JOB 2) PREVIOUS JOB COMPANY NAME FROM TO TOTAL TIME ADDRESS MO.<br><br> YR. MO. YR.<br><br> YRS. MOS. TELEPHONE NUMBER YOUR JOB TITLE HOURS PER WEEK SUPERVISOR'S NAME & TITLE STARTING SALARY $ PER REASON FOR LEAVING POSITION LAST SALARY $ PER SPECIFIC DUTIES _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ NUMBER OF EMPLOYEES SUPERVISED (IF APPLICABLE) (JOB 3) PREVIOUS JOB COMPANY NAME FROM TO TOTAL TIME ADDRESS MO.<br><br> YR. MO. YR.<br><br> YRS. MOS. TELEPHONE NUMBER YOUR JOB TITLE HOURS PER WEEK SUPERVISOR'S NAME & TITLE STARTING SALARY $ PER REASON FOR LEAVING POSITION LAST SALARY $ PER SPECIFIC DUTIES _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ NUMBER OF EMPLOYEES SUPERVISED (IF APPLICABLE) (JOB 4) PREVIOUS JOB COMPANY NAME FROM TO TOTAL TIME ADDRESS MO.<br><br> YR. MO. YR.<br><br> YRS. MOS. TELEPHONE NUMBER YOUR JOB TITLE HOURS PER WEEK SUPERVISOR'S NAME & TITLE STARTING SALARY $ PER REASON FOR LEAVING POSITION LAST SALARY $ PER SPECIFIC DUTIES _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ NUMBER OF EMPLOYEES SUPERVISED (IF APPLICABLE) MISCELLANEOUS INFORMATION IF OFFERED A JOB, ARE YOU WILLING TO UNDERGO A PRE-EMPLOYMENT PHYSICAL EXAMINATION?<br><br> YES NO IF OFFERED A JOB, ARE YOU WILLING TO UNDERGO A PRE-EMPLOYMENT DRUG SCREENING TEST? YES NO CAN YOU PERFORM THE BONA FIDE OCCUPATIONAL QUALIFICATIONS OF THE JOB YOU HAVE APPLIED FOR (WITH OR WITHOUT ACCOMMODATION)? YES NO WITHIN THE LAST SEVEN YEARS, HAVE YOU BEEN CONVICTED OF OR ARE YOU PRESENTLY CHARGED WITH A CRIME (OTHER THAN MINOR TRAFFIC VIOLATIONS) A "YES" REPLY DOES NOT AUTOMATICALLY DISQUALIFY YOU.<br><br> YES NO FOR POLICE APPLICANTS ONLY: HAVE YOU EVER BEEN CONVICTED OF OR ARE YOU PRESENTLY CHARGED WITH A CRIME (OTHER THAN MINOR TRAFFIC VIOLATIONS) ? YES NO PROFESSIONAL REFERENCES : List three professional or business references who are not your relatives or employees of the City of Port Orchard. State the nature of your business relationship (i.e., co-worker, supervisor, associate) NAME ADDRESS PHONE RELATIONSHIP YEARS KNOWN PERSONAL REFERENCES : List three personal references who are not your relatives or employees of the City of Port Orchard.<br><br> State the nature of your relationship (i.e., friend, landlord, etc.) NAME ADDRESS PHONE RELATIONSHIP YEARS KNOWN IMPORTANT: READ EACH SECTION BELOW CAREFULLY AND COMPLETELY. IF YOU DO NOT UNDERSTAND ANY PORTION OF THE STATEMENTS BELOW, ASK FOR CLARIFICATION. YOUR SIGNATURE INDICATES THAT YOU HAVE READ AND UNDERSTAND EACH OF THE PROVISIONS LISTED AND THAT YOU AGREE TO ABIDE BY THE CONDITIONS STATED THEREIN.<br><br> NOTICE TO PERSONS WITH DISABILITIES: TESTING ARRANGEMENTS TO ACCOMMODATE PERSONS WITH DISABILITIES WILL BE MADE UPON REQUEST OF THE APPLICANT. IF ACCOMMODATION IS REQUESTED, THE APPLICANT WILL BE REQUIRED TO STATE WHAT ACCOMMODATION IS NEEDED. HOW TO APPLY: APPLICATIONS FOR EMPLOYMENT SHOULD BE SUBMITTED ON OFFICIAL APPLICATION FORMS TO THE CITY OF PORT ORCHARD AT THE ADDRESS SHOWN ON PAGE 1 OF THIS APPLICATION FORM.<br><br> SUBMIT ONE APPLICATION FOR EACH POSITION. IT IS YOUR RESPONSIBILITY TO KEEP YOUR APPLICATION UP TO DATE. AN APPLICATION WILL BE REJECTED WHICH IS RECEIVED UNSIGNED, INCOMPLETE, OR AFTER THE CLOSING DATE SPECIFIED ON THE JOB ANNOUNCEMENT.<br><br> EXAMINATION PROCEDURE: YOU WILL BE NOTIFIED WITHIN FOUR WEEKS OF THE CLOSING DATE OF THE JOB ANNOUNCEMENT REGARDING ANY TESTING PROCEDURES WHICH MAY BE INVOLVED IN THE HIRING PROCESS. ANY PART OF THE ANNOUNCED EXAMINATION MAY BE ELIMINATED IF THERE IS AN INSUFFICIENT NUMBER OF APPLICANTS TO JUSTIFY GIVING THE COMPLETE EXAMINATION. PRE-EMPLOYMENT MEDICAL EXAMINATION: APPLICANTS SELECTED FOR EMPLOYMENT MAY BE REQUIRED TO PASS A MEDICAL EXAMINATION GIVEN BY A PHYSICIAN DESIGNATED BY THE CITY OF PORT ORCHARD.<br><br> PAY PLAN: NEW EMPLOYEES ORDINARILY START AT THE MINIMUM RATE IN THE SALARY RANGE. PROBATIONARY PERIOD: EMPLOYEES SERVE A PROBATIONARY PERIOD AS DETERMINED BY CITY POLICY OR BY ANY APPLICABLE COLLECTIVE BARGAINING AGREEMENT. TERMINATION OF EMPLOYMENT DURING THE PROBATIONARY PERIOD MAY BE WITH OR WITHOUT CAUSE AND IS NOT SUBJECT TO ANY APPEAL PROCESS NOR THE GRIEVANCE PROCEDURE OF ANY APPLICABLE COLLECTIVE BARGAINING AGREEMENT.<br><br> DRUG POLICY: IT IS THE POLICY OF THE CITY OF PORT ORCHARD TO MAINTAIN A DRUG FREE WORKPLACE. EMPLOYEES WHO ARE OBSERVED IN POSSESSION OF OR USING CONTROLLED SUBSTANCES (DRUGS) WILL BE TERMINATED AND MAY HAVE CRIMINAL ACTIONS FILED AGAINST THEM. EMPLOYEES IN CERTAIN POSITIONS ARE SUBJECT TO FEDERAL LAWS REQUIRING PRE-EMPLOYMENT, POST-ACCIDENT, AND RANDOM DRUG TESTING.<br><br> AGREEMENT: I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT ANY FALSIFICATION, MISREPRESENTATION OR OMISSION ON THIS APPLICATION IS GROUNDS FOR REFUSAL TO HIRE, OR IF HIRED, IS GROUND FOR TERMINATION. I AUTHORIZE ANY OF THE PERSONS OR ORGANIZATIONS REFERENCED IN THIS APPLICATION TO GIVE THE CITY OF PORT ORCHARD ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT, EDUCATION, OR ANY OTHER INFORMATION THEY MIGHT HAVE, PERSONAL OR OTHERWISE, WITH REGARD TO ANY OF THE SUBJECTS COVERED BY THIS APPLICATION. I AUTHORIZE THE CITY OF PORT ORCHARD TO REQUEST AND RECEIVE SUCH INFORMATION.<br><br> I UNDERSTAND THAT MY EMPLOYMENT CAN BE TERMINATED AT ANY TIME FOR ANY REASON THAT IS NOT VIOLATIVE OF LAW, AT THE DISCRETION OF EITHER THE CITY OF PORT ORCHARD OR MYSELF. I UNDERSTAND THAT NO MANAGEMENT OFFICIAL OTHER THAN THE CHIEF EXECUTIVE OFFICER HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT CONTRARY TO THE FOREGOING OR MAKE ANY ORAL ASSURANCE OR PROMISE OF CONTINUED EMPLOYMENT. I AGREE TO COMPLY WITH THE CITY OF PORT ORCHARD RULES, REGULATIONS AND POLICIES, AND ACKNOWLEDGE THAT THESE RULES, REGULATIONS AND POLICIES MAY BE CHANGED, INTERPRETED, WITHDRAWN, OR SUPPLEMENTED ANY TIME, AND WITHOUT PRIOR NOTICE TO ME.<br><br> I UNDERSTAND THAT THIS APPLICATION AND ANY OTHER DOCUMENTS WHICH I MAY RECEIVE ARE NOT CONTRACTS OF EMPLOYMENT. RELEASE: I HEREBY RELEASE AND HOLD HARMLESS ANY PERSON, CORPORATION, COMPANY OR OTHER ENTITY FROM ANY AND ALL POSSIBLE DAMAGES, DIRECT OR CONSEQUENTIAL, IMMEDIATE OR REMOTE, OF ALL FORMS OR TYPES, THAT I MAY SUSTAIN OR ALLEGE TO SUSTAIN BY VIRTUE OF THAT PERSON, CORPORATION, COMPANY OR OTHER ENTITY COMPLYING WITH MY REQUEST TO FULLY AND COMPLETELY COMPLY WITH THE INVESTIGATION, INQUIRY OR INTERESTS OF THE CITY OF PORT ORCHARD, TO WHOM I HAVE MADE AN APPLICATION OF EMPLOYMENT AND IS THE BEARER OF THIS AUTHORIZATION. SIGNATURE _____________________________________________ DATE ____________________________<br><br>

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