Employment Application

APPLICATION FOR EMPLOYMENT

P.O. Box 9478
Coppell, TX 75019
Fax# 972-304-3635 \ Job Line # 972-304-3542, Ext. 396
Email: HR@coppelltx.gov

The following information is requested in order to help us make the best possible placement within the City. All portions of this application pertaining to you must be completed. We appreciate the time you spend filling in this form. The City, in accordance with applicable state and federal laws, does not discriminate on the basis of age, race, religion, color, sex, national origin, marital status, physical or mental disability, arrest record, or any other characteristic protected by law.

Fields labeled in red must be filled in.

Position(s) Applied for

Referral Source	Friend/Relative Job Line/C-Link Dallas Morning News Ft. Worth Star Telegram	Walk-In Web Page Denton Chronicle DFW Newspapers		Employment Agency Job Fair Employment News
	-other- (please specify):

Last Name	First Middle

Address
	City State Zip

Telephone	Area Code ( ) Number		Social Security Number

Email Address

Are you at least 18 years old? Yes No

If employed and you are under 18 can you furnish a work permit? Yes No

Have you ever been employed here before? Yes No
If "Yes" give date (mm/dd/yyyy)
Position(s) Held

Are you employed now? Yes No
If "Yes," may we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No

On what date would you be available for work? (mm/dd/yyyy)

Have you ever been convicted of, or have you pleaded guilty or no contest (nolo contendere) to a crime? Is there a criminal matter currently pending against you? Yes No (NOTE: Answering "yes" will not automatically bar you from employment.) If "yes," describe in full below.

If the position/job you are applying for requires lifting, bending, stooping, climbing, reaching, pulling, pushing and any other physical effort to perform the assigned tasks, are you able to perform these physical efforts?				Yes No

Education	Elementary	High	Trade
School Name
Years Completed
Diploma/Degree	n/a
Course of Study	n/a

	College/ University	Graduate/ Professional
School Name
Years Completed
Diploma/Degree
Course of Study

Describe Specialized Training, Apprenticeship Skills and Extra Curricular Activities relevant to the position for which you are applying:

Indicate languages you speak, read and/or write

	Fluent	Good	Fair
Speak
Read
Write

Employment Experience

Please list your complete full time, and part-time employment history. Start with your present or most recent job, including military service assignments. We will probably contact the employer listed below unless you specifically indicate those employers whom you do not want us to contact, and give the reason(s) for your request.

1. Employer	Dates Employed
	From (mm/dd/yyyy)	To (mm/dd/yyyy)	Work Performed
Name
Telephone	Hourly Rate/Salary
Address	Starting	Final
Job Title
Supervisor
Reason for Leaving
May we contact this employer? Yes No If "No," please state reason

2. Employer	Dates Employed
	From (mm/dd/yyyy)	To (mm/dd/yyyy)	Work Performed
Name
Telephone	Hourly Rate/Salary
Address	Starting	Final
Job Title
Supervisor
Reason for Leaving
May we contact this employer? Yes No If "No," please state reason

3. Employer	Dates Employed
	From (mm/dd/yyyy)	To (mm/dd/yyyy)	Work Performed
Name
Telephone	Hourly Rate/Salary
Address	Starting	Final
Job Title
Supervisor
Reason for Leaving
May we contact this employer? Yes No If "No," please state reason

4. Employer	Dates Employed
	From (mm/dd/yyyy)	To (mm/dd/yyyy)	Work Performed
Name
Telephone	Hourly Rate/Salary
Address	Starting	Final
Job Title
Supervisor
Reason for Leaving
May we contact this employer? Yes No If "No," please state reason

5. Employer	Dates Employed
	From (mm/dd/yyyy)	To (mm/dd/yyyy)	Work Performed
Name
Telephone	Hourly Rate/Salary
Address	Starting	Final
Job Title
Supervisor
Reason for Leaving
May we contact this employer? Yes No If "No," please state reason

References

Give name, address and telephone number of three references who are not related to you and are not previous employers.
Name	Address	Telephone
1
2
3

State name(s) of relatives working for us, other than your spouse:

Special Skills and Qualifications

List professional trade, business, or civic activities including offices held which are relevant to the position(s) for which you are applying. (You may exclude those, which indicate race, color. religion, sex, national origin, age, disability, or any other characteristic protected by law.)

Summarize special skills and qualifications acquired from employment or other experience, which are relevant to the position(s) for which you are applying.

Statement of ADA Compliance

The city of Coppell acknowledges its responsibility to comply with Americans with Disabilities Act of 1990. Thus, in order to assist individuals with disabilities who require special services (i.e. sign interpretive services, alternative audio/visual devices, and amanuenses) for participation in or access to the city of Coppell recruitment process, the city requests that individuals make requests for these services forty-eight (48) hours ahead of the scheduled assessment and/or interview. To make arrangements, contact Vivyon Bowman, ADA Coordinator, or other designated official at 972-462-0022, or (TDD 1-800-RELAY, Tx. 1-800-735-2989).

The City of Coppell is an Equal Opportunity Employer

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the information contained in this application is true and correct and that I have not omitted any information. I understand that the false or misleading information given in my application or interview(s) may disqualify me from further consideration, or if hired, may result in my dismissal from employment. I agree to abide by the rules and regulations of the City, and understand that my employment and my compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the City or myself. I further understand that no representative of the City, other than the City Manager, has the authority to enter into any agreement of employment for any specified period of time, and that any such agreement must be in writing and signed by both the City Manager and me. I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize the City to (1) investigate the truthfulness and completeness of all statements made on this application; (2) contact my schools, former and current employers, (except those employers which I have specifically stated on page 3 may not be contacted) and other listed references or any other persons who can verify information including local, state, and federal law enforcement personnel; and (3) discuss the results of any investigation with other employees of the City involved in the hiring process. In addition, I give my consent for all contacted persons including former and current employers to provide information concerning this application, and I release the City and each such person from liability that may result from the release and / or use of such information.

I have read and understand the paragraph above Yes No

City of Coppell
Applicants Drug and Alcohol Policy Acknowledge & Consent

I understand that if I am offered a position with the City of Coppell, my employment is contingent upon my passing a drug test to determine the presence of alcohol or other drugs in my system. I understand that I will not be employed if the test indicates the presence of alcohol or illegal or unauthorized drugs in my system, I will have failed the application process and will not be hired.

I hereby consent to a blood test, Breathalyzer, urinalysis, or hair sample tests, to be administered by a physician or medical facility selected by the City of Coppell, to be done at the City's expense. I further consent to the disclosure of the results of the drug test to the City of Coppell. I hereby release the City of Coppell from any and all liability of any kind resulting from the testing procedure or the transfer of information obtained therefrom. My signature hereon shall indicate my acknowledgement that I have read the foregoing, or that it has been read to me, and that I understand it fully.

I have read and consent to the paragraph above Yes No

Thank you for applying with the city of Coppell. You have now completed the on-line job application. If you would like to attach an electronic copy of your resume please click on the Add Resume button. If you would like to submit your application without a resume please click on the Submit without Resume button.

Note: any information required for the processing of this application that was left blank or incomplete will be indicated when the application is submitted.