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2. Position Applied For*
   -- Select One --Grounds Maintenance Worker IPolice OfficerLine Maintenance Worker IMaintenance Worker I Streets & Utility MaintenanceCommunications Specialist IYouth Services LibrarianPart-Time Kennel TechSports and Recreation CoordinatorOther
3. Other:
5. CONTACT INFORMATION
7. Full Legal Name:*
9. Cell Phone: *
10. Home Phone: *
12. Current Street Address:*
14. City, State:*
15. ZIP Code:*
17. Email Address:*
21. EDUCATION
23. Select the highest grade completed*
    -- Select One --6789101112GED
24. Did you graduate from High School?*

    1. Yes
    2. No
26. Select years of college completed.
    -- Select One --123456PLUS
27. Did you graduate from College?*

    1. Yes
    2. No
29. Name & Location of School*
31. Type of School*
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther
32. Course of Study*
33. Years Completed & Degree*
35. Add additional education?*

    1. Yes
    2. No
37. Name & Location of School
39. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther
40. Course of Study
41. Years Completed & Degree
43. Add additional education?

    1. Yes
    2. No
45. Name & Location of School
47. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther
48. Course of Study
49. Years Completed & Degree
51. Add additional education?

    1. Yes
    2. No
53. Name & Location of School
55. Type of School
    -- Select One --High SchoolUndergraduate GraduateBusiness/TradeOther
56. Course of Study
57. Years Completed & Degree
59. Add additional education?

    1. Yes
    2. No
61. Name & Location of School
63. Type of School
    -- Select One --High SchoolUndergraduateGraduateBusiness/TradeOther
64. Course of Study
65. Years Completed & Degree
69. How did you hear about this job?*

    1. Chickasha.org
    2. Indeed.com

    1. City Staff
    2. Volunteer

    1. *Other
71. *If other, please explain:
75. BACKGROUND
77. Are you currently employed by the City of Chickasha, OK in any capacity (including part time or seasonal contract)?*

    1. No
    2. Yes
79. Have you ever been employed by the City of Chickasha, OK?*

    1. No
    2. Yes
81. Are you related to any City of Chickasha employee or any City of Chickasha Council Member?*

    1. No
    2. *Yes
83. *If yes, list name and relation:
85. Have you ever volunteered with the City of Chickasha?*

    1. No
    2. *Yes
87. *If yes, please list department and dates below:
89. 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:
91. Date
92. Charge
93. Location (City, State)
94. Current Status
96. Date
97. Charge
98. Location
99. Current Status
101. Are criminal charges currently pending against you? *

     1. No
     2. Yes* - If yes, please supply details:
103. Details of pending criminal charges:
105. Do you have a valid Oklahoma driver's license? *

     1. No
     2. Yes
106. Are you over 18 years old? *

     1. No
     2. Yes
108. Are you aware of the policy of the City of Chickasha regarding drugs and alcohol in the work place?*

     1. No
     2. Yes
112. WORK EXPERIENCE
     List most recent employer first.
114. Employer/Company:
115. Address:
117. Supervisor:
118. Phone:
120. Your job title:
121. Start & End Date
     Start & End Date Start Date

     —

     Start & End Date End Date
123. Job duties:
124. I am currently employed here.

     1. Yes
126. 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.
128. Reason we may not contact employer listed above:
132. Employer/Company:
133. Address:
135. Supervisor:
136. Phone:
138. Your job title:
139. Start & End Date:
     Start & End Date: Start Date

     —

     Start & End Date: End Date
141. Job duties:
142. Provide reason for leaving:
144. 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.
146. Reason we may not contact employer listed above:
150. 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.):
154. MILITARY
156. Have you ever served on active duty in the U.S. Armed Forces? *

     1. No
     2. Yes
158. Branch:
159. Dates of Service:
     Dates of Service: Start Date

     —

     Dates of Service: End Date
161. Describe any training received relevant to the position for which you are applying:
165. REFERENCES
     Please list two professional references other than family members.
167. Name: *
168. Phone Number: *
170. How do they know you? *
171. How many years have they known you? *
175. Name: *
176. Phone Number: *
178. How do they know you? *
179. How many years have they known you? *
183. Résumé
     If you would like to attach a résumé, please click "browse" above and upload the document.
184. Additional documentation
     If you would like to attach any additional documentation, please use the box above to upload the document.
188. 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.
190. Please type your full name below to sign your application.*
191. Today's Date:*
     Today's Date:
Leave This Blank:


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

     This field is not part of the form submission.

195. Submit Submit and Print

* indicates a required field