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Personal Information

Application for Employment
An incomplete application may affect your consideration for employment. If necessary, attach a separate sheet for additional information. The City of Russellville is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, religion, creed, national origin or ancestry, sex, age, physical or mental disability, veteran status, genetic information or any other legally recognized protected basis under federal, state or local laws, regulations or ordinances.

Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and ensure an equal employment opportunity without imposing undue hardship on the City of Russellville. Please inform the Human Resources Coordinator at 479-968-2098 if you need assistance completing any forms or to otherwise participate in the application process.
First Name*
Middle Name*
Last Name*
Address*
Address
City*
State*
Zip*
Phone Number*
Email Address
Alternate Contact Number
Starting Date Available for Work*
Starting Date Available for Work
Are you eligible to work in the United States?*
1. Yes
1. No
Do you now, or will you in the future, require immigration sponsorship for work authorization (e.g., H-1B)?*
1. Yes
1. No
Are you under the age of 18?*
1. Yes
1. No
If you are under the age of 18, please state your age.
The primary reason for this question is to address any child labor laws.
How were you referred to the City of Russellville?*
Do you have any relatives employed by the city?*
1. Yes
1. No
If you selected yes to the question above, you must list your relatives name below and relationship to you.
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Position Information

Type of work desired?*
Type of employment desired*
1. Full Time
1. Part Time
1. Internship
Salary Range Expected*
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Employment History

References

Please list 3 professional references.
Full Name*
Type of Acquaintance*
Email Address*
Phone Number*
Full Name*
Type of Aquaintance*
Email Address*
Phone Number*
Full Name*
Type of Aquaintance*
Email Address*
Phone Number*
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Education

High School or G.E.D. Equivalent
School Name & Location
Highest Grade Completed
1. 9
2. 10
3. 11
4. 12
5. GED
Grade Point Average
Course of Study or Major
College or University
School Name & Location
Highest Grade Completed
1. 1
2. 2
3. 3
4. 4
Grade Point Average
Course of Study or Major
Vocational or Trade School
School Name & Location
Highest Grade Completed
Grade Point Average
Course of Study or Major
Graduate School
School Name & Location
Highest Grade Completed
Grade Point Average
Course of Study or Major
Other (Including Military Training)
School Name & Location
Highest Grade Completed
Grade Point Average
Course of Study or Major
List any work-related certifications or licenses you currently possess.
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Background Information

During the past 7 years, have you ever been discharged, suspended, or asked to resign from any positions?*
1. Yes
1. No
For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?*
1. Yes
1. No
If yes, please specify name.
Have you ever been convicted of a crime that has not been expunged, sealed, pardoned, annulled, statutorily eradicated or dismissed upon condition of probation? You are not required to disclose seals or expunged records of conviction or arrest, or expunged juvenile records of conviction or arrest.*
1. Yes
1. No Record
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Disclaimer & Signature

Initials*
I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.
Initials*
I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drugs before being permitted to commence work with the City of Russellville.
Initials*
I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with the City of Russellville.
Initials*
I hereby certify that the information given by me is true in all respects. I authorize the City of Russellville and its representatives to contact my prior employers and all others for the purpose of verification of the information I have supplied and released same from any liability resulting from the information released. I authorize employers, schools, and other persons named on this application to provide any information or transcripts requested.
Initials*
I understand that employment with the City of Russellville is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.
Initials*
I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at will, with or without cause, be either the City of Russellville or me without prior notice to the other, unless otherwise prohibited by law.
Initials*
I understand that no representation, whether oral or written, by any representative or agent of the City of Russellville, at any time, can constitute and implied or expressed contract of employment. I further understand no representative or agent of the City of Russellville has the authority to enter into an agreement for employment for any specified period of time or to make any changes in any policy, procedure, benefit, or other terms or conditions of employment other than in a document signed by the mayor or an authorized representative.
I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any falsification or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time lapse before discovery.
An offer of employment is conditioned upon complying with the City of Russellville's requirements including, but not limited to, signing consent to conduct a background investigation.
My signature is evidence that I have read and agree with the above statements.
Applicant's Signature*
Date*
Date
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Biographical Information for Employment Background Check

First Name
Middle Name
Last Name
Social Security Number
Former Names
Name as it appears on Driver's License
State of Issue
Date of Birth
Please provide all addresses where you have lived for the past seven years including zip codes
Current Address First going back 7 years
Street Number
Street Name
Street Type
Apt #
City
State
ZIP
Years Lived There
Street Number
Street Name
Street Type
Apt #
City
State
ZIP
Years Lived There
Street Number
Street Name
Street Type
Apt #
City
State
ZIP
Years Lived There
Street Number
Street Name
Street Type
Apt #
City
State
ZIP
Years Lived There
Street Number
Street Name
Street Type
Apt #
City
State
ZIP
Years Lived There
Applicant's Signature*
Date*
Date
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Disclosure & Authorization

Disclosure, Authorization & Consent for Pre-Employment Screening Report
I, the applicant, in connection with my application for employment at the City of Russellville hereby authorize the employer and any agent it authorizes to perform a pre-employment background screening check (including future screening for retention, promotion, or reassignment if applicable unless revoked in writing.)

I understand and agree to the following:
I understand that the employer may obtain a report, which consists of information having a bearing on job performance, and may include information from public and private sources, public records, courts, schools, former employers, and references on my driving record, court records, worker's compensation record, education, credentials, identity, and previous employment.

I understand and release people, companies, references, current and former employers, schools, municipal, county, state and federal agencies and courts, to provide all information that is requested to the employer or its authorized agents. I further release and hold harmless all of the above, including the employer, to the full extent permitted by law, from any liability or claims arising from retrieving and reporting of information concerning me. I agree that a copy or fax of this document shall be as valid as the original. I certify that the following facts and the information in my resume and/or application are true and correct.
Have you ever been convicted of a crime?
Please exclude convictions that have been sealed or legally eradicated and misdemeanor conviction for which probation was completed and the cases were dismissed).
1. Yes
1. No
Are you currently on bail or released on your own recognizance pending trial?
1. Yes
1. No
If the answer to either one is yes, please explain on a separate piece of paper.
An affirmative answer to any of the above will not necessarily disqualify you from employment.
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I verify and affirm that all information on this form is true and correct. Any false information or material omission is grounds to terminate the hiring process or to terminate employment if it has stated.
Signature*
Date*
Date
The City of Russellville is an Equal Opportunity Employer

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Email address

This field is not part of the form submission.
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