Employment Application Template	Return to: Administration CITY OF BLOOMFIELD 915 N First St. Bloomfield, NM 87413 Fax (505) 632-6310 Tel. (505) 632-6300

**** Please Type or Print Clearly in Ink ****

Position Applied: Click or tap to enter text Date of Application: Click or tap to enter a date.

Name: _________________________________________________________/ __________________________________

Last	First	Middle Initial	(List any names previously used or known by, i.e. maiden name)

Address: _________________________________________________Email Address: Enter your email address

Street/P.O. Box	City	State	Zip Code	Email is Required for status & employment updates

Telephone Number Click or tap to enter text Social Security Number: Click or tap to enter text

May we contact you at work? ☐ yes ☐ no

Work number Click or tap to enter text Best time to call: Click or tap to enter text

If you are under 18, can you provide proof of eligibility to work?	☐ yes ☐ no

Have you ever filed an application with us before? ☐ yes ☐ no if yes, give date: Tap To Enter Date

Have you ever been employed by the City of Bloomfield? ☐yes ☐ no

If yes, give dates:	From Click or tap to enter a date. To Click or tap to enter a date.

Are you related to any City employee or elected City official? ☐ yes ☐ no

If yes, who and what is the relationship? Click or tap to enter text

Are you legally eligible for employment in the United States? ☐ yes ☐ no

(Proof of U.S. Citizenship or immigration status will be required upon employment)

Date available for work: CLICK OR TAP TO ENTER A DATE. Comments: Click or tap to enter text

Employment desired: ☐ Full-Time ☐ Part-Time ☐ Temporary ☐ Seasonal

Are you on a lay-off subject to recall? ☐ yes ☐ no

Have you ever been bonded? ☐ yes ☐ no

Please provide the following: Driver's License Number Click or tap to enter text State Click or tap to enter text

How did you learn of this position? ☐ Newspaper ☐ Referral ☐ Website ☐ Other: Click or tap to enter text

EMPLOYMENT HISTORY: List your employment history for the past ten (10) years, including military experience. Explain any gaps in employment in the COMMENTS Section. Do not make reference to resumes.
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
EMPLOYMENT HISTORY CONTINUED: List your employment history for the past ten (10) years, including military experience. Explain any gaps in employment in the COMMENTS Section. No reference to resumes.
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
Employer: Click or tap to enter text	Telephone: tap to enter text	Dates Employed:
Address: Click or tap to enter text	From: Tap to Enter Date
Job Title: Click or tap to enter text	To: Tap to Enter Date
Immediate Supervisor and Title: Click or tap to enter text	Hourly Rate / Salary:
Reason for Leaving: Click or tap to enter text	Start: Tap to Enter text
Summarize work performed/job responsibilities: Click or tap to enter text	Final: Tap to Enter text
Click or tap to enter text	May we contact for reference?
Click or tap to enter text	☐ Yes ☐ No ☐ Later
EDUCATIONAL BACKGROUND
List last three schools attended, including high school, starting with most recent.	Number years completed.	Indicate degree or diploma earned, if any.	Grade Point Average or Class Rank	Major (if applicable)	Minor (if applicable)
1) Click or tap to enter text	Enter years	Enter degree	Enter GPA	Enter major	Enter minor
2) Click or tap to enter text	Enter years	Enter degree	Enter years	Enter degree	Enter minor
3) Click or tap to enter text	Enter years	Enter degree	Enter years	Enter degree	Enter minor
LANGUAGE: List the language(s) you use; check the box that describes your skill level (English, Spanish, etc.).
Read	Write	Speak
1) Click or tap to enter text	☐	☐	☐
2) Click or tap to enter text	☐	☐	☐
SKILLS AND QUALIFICATIONS: Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with the City.
☐ Typing __wpm: tap to enter text	☐ Word ☐ Access ☐ Other
☐ Windows	☐ Excel ☐ PowerPoint
Other Job-Related Skills, Training, Qualifications: Click or tap to enter text
Click or tap to enter text
REFERENCES: List three personal references not related to you.
Name	Telephone	Years Known
1) Click or tap to enter text	Click or tap to enter text	Click to Enter
2) Click or tap to enter text	Click or tap to enter text	Click to Enter
3) Click or tap to enter text	Click or tap to enter text	Click to Enter
ADDITIONAL INFORMATION
List professional trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, disability or protected status).
Organization	Offices held
Click or tap to enter text	Click or tap to enter text
Click or tap to enter text	Click or tap to enter text
List special accomplishments, publications, awards. Click or tap to enter text (Exclude information which would reveal sex, race, religion, national origin, age, ancestry, disability or protected status).
Click or tap to enter text
Click or tap to enter text
COMMENTS: Click or tap to enter text
Click or tap to enter text
Click or tap to enter text

PLEASE READ AND SIGN THE STATEMENTS BELOW

(Unsigned applications will be rejected and not be considered):

The facts set forth in my application for employment are true and complete, to the best of my knowledge. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. I authorize any of my previous employers, schools, or persons named as references to give any information regarding employment or educational record. I agree that the City of Bloomfield and my previous employers shall not be held liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statements, omissions or answers made by me on this application.

Note: It is hereby understood and agreed that if hired by the City of Bloomfield, I will be employed on a probationary basis for a period of twelve (12) months.

Applicant Signature ______________________________________________	Date: _____/_____/_____

PRE-EMPLOYMENT PHYSICAL/DRUG SCREENING ACKNOWLEDGMENT AND AGREEMENT

By my signature below, I _______________________________, realize and understand that if considered for employment with the City of Bloomfield, I will be required to submit to a pre-employment physical/drug screen test as a condition of hire. The City of Bloomfield will pay for this drug screening.

My signature below also serves to acknowledge and agree to the fact that if I receive a preliminary offer of employment with the City of Bloomfield, and accept it, one factor that must be met PRIOR to a final offer of employment being made is the successful completion of a physical/drug screen test. Successful completion of a drug-screening test is defined as test results showing no trace of drugs. If successful completion of a drug-screening test is not obtained, I understand I will not be eligible for hire with the City of Bloomfield.

Applicant Signature ______________________________________________	Date: _____/_____/_____

AUTHORIZATION FOR RELEASE OF

CRIMINAL ARRESTS AND DRIVING RECORD

I authorize the City of Bloomfield to obtain criminal arrests and driving record information about me from law enforcement agencies, courts of law, and motor vehicle departments, of any state in which I reside (or have resided).

Applicant Signature ______________________________________________	Date: _____/_____/_____

The City of Bloomfield is an Equal Opportunity Employer

EMPLOYMENT REFERENCE WAIVER

Note: This waiver must be signed in the presence of a Notary Public.

I, _____________________________, have made application with the City of Bloomfield, New Mexico for the position of _____________________________.

I hereby authorize the City of Bloomfield Human Resource Department or the City of Bloomfield Police Department to thoroughly investigate my references, work record, education and other matters related to my suitability for employment. Further, authorize past employers and the references I have listed to disclose to the City of Bloomfield any and all information pertinent to my employment with the City of Bloomfield without giving me prior notice of such disclosure. Any information obtained could be confidential or privileged in nature. In addition, I hereby release the City of Bloomfield, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation of disclosure.

A photocopy or fax copy of this release form will be valid as an original thereof, even though the said photocopy or fax does not contain an original writing of my signature.

________________________________ ____________________________

Signature	Date

________________________________ ____________________________

Printed Name SS Number

________________________________________________________________________

Address

County of San Juan

State of New Mexico

Subscribed and sworn to before me by ___________________________ on this ____

day of ____________________, 20____.

My commission expires: _______________________________

Notary Public

AFFIRMATIVE ACTION INFORMATION SURVEY

The City of Bloomfield is a government entity, subject to government regulations and affirmative action guidelines.

To assist with government reporting purposes, please fill out this confidential survey. The information that you provide on this survey is voluntary, confidential, and will not be kept with your application. You are not required to provide the information on this form and refusal to provide such information will in no way affect your status as an applicant.

Please DO NOT staple or paperclip to application.

PLEASE PRINT

Date:_____________________ Name (Last, First):__________________________________

Position Applied For:______________________________________________________

REFERRAL SOURCE: ☐ College Recruitment ☐ High School ☐ Employment Agency ☐ Job Service ☐ City Hall Postings ☐ City's Website Posting ☐ Previous City Employee ☐ Radio/TV Ad Name: Click or tap here to enter text. ☐ News Paper Ad Name: Click or tap here to enter text. ☐ Employee Referral Name: Click or tap here to enter text. ☐ Other__________________	CHECK ONE: ☐ Male ☐ Female CHECK ONE OF THE FOLLOWING ETHNIC GROUPS: ☐ American Indian / Alaskan Native ☐ Asian / Pacific Islander ☐ Black ☐ Caucasian / White (not Hispanic origin) ☐ Hispanic CHECK YES OR NO TO THE FOLLOWING QUESTIONS: VETERAN ☐ Yes ☐ No AGE 40-70 ☐ Yes ☐ No