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VILLAGE OF CLEMMONS EMPLOYMENT APPLICATION
Fill out all sections of this application completely and to the best of your ability. Your application will be used as part of the examination process and, therefore, should represent your best effort. Unsigned and incomplete applications may not be considered. Once submitted, application materials become the property of the Village. Applications from applicants not hired will remain on file for two years.
Position Applied For
Date
Date
When Will You Be Available for Employment
Salary Desired
Name
Address
Telephone
Alternate Telephone
Email Address
Are you 18 or older?
1. Yes
1. No
Cover Letter
Resume
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General Information

Education

High School
Name & Location
Did you graduate?
1. Yes
1. No
Diploma, Certificate or Degree Earned
Major/Minor Subject
Technical Institute
Name & Location
Did you graduate?
1. Yes
1. No
Diploma, Certificate or Degree Earned
Major/Minor Subject
College
Did you graduate?
1. Yes
1. No
Name & Location
Major/Minor Subject
Graduate School
Name & Location
Did you graduate?
1. Yes
1. No
Diploma, Certificate or Degree Earned
Major/Minor Subject
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Skills, Knowledge & Abilities

Please list any skills, knowledge or abilities you have that you feel are applicable to the position for which you are applying. Include skills with equipment or machines you operate.
List fields of work for which you have been registered, licensed or certified.
Registration
State
Number
Expiration Date
Registration
State
Number
Expiration Date
Other
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Military Service

Branch of Service
Years of Service
Type of Discharge
Rank at Time of Discharge
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Volunteer Experience

Please share any volunteer experiences that relate to the position to which you are applying.
Organization
Duties
Years of Service
Organization
Duties
Years of Service
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Employment

Date Employed
Date Separated
Employer
Supervisor's Name
Address
Telephone Number
Job Title
Duties in Order of Importance
Starting Salary
Ending Salary
Reason for Leaving
Date Employed
Date Separated
Employer
Supervisor's Name
Address
Telephone Number
Job Title
Duties in Order of Importance
Starting Salary
Ending Salary
Reason for Leaving
Date Employed
Date Separated
Employer
Supervisor's Name
Address
Telephone Number
Job Title
Duties in Order of Importance
Starting Salary
Ending Salary
Reason for Leaving
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Personal References

Please list three references that have personal knowledge of your work performance. Do not include family members or past supervisors.
Name
Phone Number
Relationship
Address
Years Known
Name
Phone Number
Relationship
Address
Years Known
Name
Phone Number
Relationship
Address
Years Known
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Other Information

Have you had disciplinary action taken against you in the past 12 months of employment?
1. Yes
1. No
Explain
Have you ever been dismissed or forced to resign from any job?
1. Yes
1. No
Explain
May we contact your present employer for reference?
1. Yes
1. No
I authorize the Village of Clemmons to conduct a personal background investigation in connection with my application. This investigation may include information from educational institutions, police and /or court records, Department of Motor Vehicle records, listed personal references and/or other references, previous employers and other appropriate sources.
I authorize the release of any information the Village of Clemmons may request from the above sources. I further waive all rights to inspection or review of any information compiled.
I fully understand all information gained from such investigation is confidential.
I agree to provide any further information which may be requested and hereby certify that there are no willful or negligent misrepresentations, omissions, or falsifications in the application or documents furnished or answers to questions. I am aware should any investigation disclose any willful misrepresentations, omissions, or falsifications that my application may be rejected. Additionally, I am aware that willful misrepresentations, omissions, or falsifications in the application or documents furnished or answers to questions are grounds for termination should I be employed by the Village of Clemmons.
I hereby release the Village of Clemmons, its agents and representatives and any person(s) so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such document, record, and other information for the investigation made by the Village of Clemmons.
Furthermore, I understand that employment with the Village of Clemmons is contingent upon the successful completion of a drug-screening test to be administered after an offer of employment is made. (Successful completion of the test means that the person tested negative for illegal drugs and substance abuse.)
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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