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Employment Application

2. Position Applied For: *

4. CONTACT INFORMATION

6. Full Legal Name:*

8. Cell Phone: *

9. Home Phone: *

11. Current Street Address:*

13. City, State:*

14. ZIP Code:*

16. Email Address:*

20. EDUCATION

22. Select the highest grade completed*
    -- Select One --6789101112GED

23. Did you graduate from High School?*

    1. Yes
    2. No

25. Select years of college completed.
    -- Select One --123456PLUS

26. Did you graduate from College?*

    1. Yes
    2. No

28. Name & Location of School*

30. Type of School*
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther

31. Course of Study*

32. Years Completed & Degree*

34. Add additional education?*

    1. Yes
    2. No

36. Name & Location of School

38. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther

39. Course of Study

40. Years Completed & Degree

42. Add additional education?

    1. Yes
    2. No

44. Name & Location of School

46. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther

47. Course of Study

48. Years Completed & Degree

50. Add additional education?

    1. Yes
    2. No

52. Name & Location of School

54. Type of School
    -- Select One --High SchoolUndergraduate GraduateBusiness/TradeOther

55. Course of Study

56. Years Completed & Degree

58. Add additional education?

    1. Yes
    2. No

60. Name & Location of School

62. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther

63. Course of Study

64. Years Completed & Degree

68. How did you hear about this job?*

    1. Chickasha.org
    2. Indeed.com

    1. City Staff
    2. Volunteer

    1. *Other

70. *If other, please explain:

74. BACKGROUND

76. Are you currently employed by the City of Chickasha, OK in any capacity (including part time or seasonal contract)?*

    1. No
    2. Yes

78. Have you ever been employed by the City of Chickasha, OK?*

    1. No
    2. Yes

80. Are you related to any City of Chickasha employee or any City of Chickasha Council Member?*

    1. No
    2. *Yes

82. *If yes, list name and relation:

84. Have you ever volunteered with the City of Chickasha?*

    1. No
    2. *Yes

86. *If yes, please list department and dates below:

88. Have you ever been convincted of any criminal offense, pleaded guilty or solo contenders, or been found guilty of a criminal offense, even though adjudication was withheld or sentence was suspended?*

    1. No
    2. *Yes - If yes, please give the following information:

90. Date

91. Charge

92. Location (City, State)

93. Current Status

95. Date

96. Charge

97. Location

98. Current Status

100. Are criminal charges currently pending against you? *

     1. No
     2. Yes* - If yes, please supply details:

102. Details of pending criminal charges:

104. Do you have a valid Oklahoma driver's license? *

     1. No
     2. Yes

105. Are you over 18 years old? *

     1. No
     2. Yes

107. Are you aware of the policy of the City of Chickasha regarding drugs and alcohol in the work place?*

     1. No
     2. Yes

111. WORK EXPERIENCE
     List most recent employer first.

     List most recent employer first.

113. Employer/Company:

114. Address:

116. Supervisor:

117. Phone:

119. Your job title:

120. Start & End Date
     Start & End Date Start Date

     —

     Start & End Date End Date

122. Job duties:

123. I am currently employed here.

     1. Yes

125. We may contact employers listed unless you indicate those you do not wish for us to contact.

     May we contact this employer?

     1. Yes
     2. *No - If no, please provide reason.
127. Reason we may not contact employer listed above:

131. Employer/Company:

132. Address:

134. Supervisor:

135. Phone:

137. Your job title:

138. Start & End Date:
     Start & End Date: Start Date

     —

     Start & End Date: End Date

140. Job duties:

141. Provide reason for leaving:

143. We may contact employers listed unless you indicate those you do not wish for us to contact.

     May we contact this employer?

     1. Yes
     2. *No - If no, please provide reason.
145. Reason we may not contact employer listed above:

149. Please list any special experience, knowledge or skills you have, that may be helpful to the City of Chickasha (i.e. fluency in another language, computer programming, etc.):

153. MILITARY

155. Have you ever served on active duty in the U.S. Armed Forces? *

     1. No
     2. Yes

157. Branch:

158. Dates of Service:
     Dates of Service: Start Date

     —

     Dates of Service: End Date

160. Describe any training received relevant to the position for which you are applying:

164. REFERENCES
     Please list two professional references other than family members.

     Please list two professional references other than family members.

166. Name: *

167. Phone Number: *

169. How do they know you? *

170. How many years have they known you? *

174. Name: *

175. Phone Number: *

177. How do they know you? *

178. How many years have they known you? *

182. Résumé

     If you would like to attach a résumé, please click "browse" above and upload the document.

183. Additional documentation

     If you would like to attach any additional documentation, please use the box above to upload the document.

187. Digital signature
     Please type your name below and click submit. By typing your name and submitting, you are certifying that all information on this application is true. Submitting an application does not guarantee employment with the City of Chickasha. A City of Chickasha representative will follow up with next steps or to obtain additional information, if needed.

     Please type your name below and click submit. By typing your name and submitting, you are certifying that all information on this application is true. Submitting an application does not guarantee employment with the City of Chickasha. A City of Chickasha representative will follow up with next steps or to obtain additional information, if needed.

189. Please type your full name below to sign your application.*

190. Today's Date:*
     Today's Date:

Leave This Blank:


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

     This field is not part of the form submission.

193. Submit Submit and Print

* indicates a required field