VILLAGE OF CHAPIN 510 EVERETT STREET
APPLICATION P.O. BOX 213
FOR EMPLOYMENT CHAPIN, ILLINOIS 62628
(217) 472-3111
The Village of Chapin considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
(PLEASE PRINT)
Position Applied for: _________________ Date of Application: ___________________
How Did You Learn About Us?
___Advertisement ___Friend ___Walk-In ___Employment Agency
___Relative ___Other
Last Name____________________ First Name_______________ Middle Name_________________
Address______________________ City________________State__________Zip_____________________
Telephone Number___________________________Social Security Number________________________
If you are under 18 years of age, can you provide required proof of your eligibility to work? ___ Y___ N
Have you ever filed an application with us before? ___Y___ N
If Yes, give date______________________
Have you ever been employed with us before? ___ Y___ N
If Yes, give date______________________
Are you currently employed? ___ Y___ N
May we contact your present employer ___Y___ N
Are you prevented from lawfully becoming employed in this
Country because of Visa or Immigration status? ___Y___ N
Proof of citizenship or immigration status will be required upon employment.
On what date would you be available for work? ______________
Are you available to work: ___Full Time ___Part Time ___Shift Work ___Temporary
Are you currently on “lay-off” status and subject to recall? ___Y___N
Can you travel if a job requires it? ___Y___N
Have you been convicted of a felony or misdemeanor? ___Y___N
Conviction will not necessarily disqualify an applicant from employment
If Yes, please explain__________________________________________________________________
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
EDUCATION
HIGH SCHOOL
Name of High School ____________________________________________________________________
Address of High School___________________________________________________________________
Did you graduate from high school? Yes: _____No:_____If yes, when did you graduate? _______________
If no, which grade did you complete? _______ When did you complete that grade? _______________
COLLEGE
Did you attend a college/university? _________________________________________________________
If yes, please state the name of the college/university: ___________________________________________
Address of college/university: ______________________________________________________________
Number of years attended: 1 2 3 4. Did you receive a degree or diploma? _______When? _________
OTHER POST-HIGH SCHOOL EDUCATION
Did you attend a trade or technical training school? _____________________________________________
If yes, please state the name of the school: ____________________________________________________
School address: _________________________________________________________________________
Number of years attended: 1 2 3 4. Did you receive a degree or diploma? _______When? _________
POST COLLEGE EDUCATION
Did you attend a graduate school? ___________________________________________________________
If yes, please state the name of the graduate school: _____________________________________________
School Address: _________________________________________________________________________
Number of years attended: 1 2 3 4. Did you receive a degree or diploma? ________ When? _______
Please list the nature of any degrees or diploma you received and the date you received each degree or diploma which you believe makes you qualified for employment at The Village of Chapin in the position for which you are applying: ________________________________________________________________
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Indicate any foreign languages you can speak, read and/or write.
Speak________ Fluent_________ Good_________ Fair
Read_________ Fluent_________ Good_________Fair
Write_________ Fluent_________ Good _________Fair
Describe any specialized training, apprenticeship, skills and extra-curricular activities that may relate to your qualifications for the job for which you are making application.
______________________________________________________________________________________
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Describe any job-related training received in the United States military.
______________________________________________________________________________________
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EMPLOYEMENT & RELATED EXPERIENCE
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. Do not exclude any employment or work.
1. Employer: _________________________________Dates Employed: From________To____________
Address: ______________________________________________________________________________
Telephone Number(s):__________________________________ Starting Salary: ____________________
Ending Salary: _________________________
Job Title: _________________________________ Supervisor: __________________________________
Work Performed: ________________________________________________________________________
______________________________________________________________________________________
2. Employer: _________________________________Dates Employed: From________To____________
Address: ______________________________________________________________________________
Telephone Number(s):__________________________________ Starting Salary: ____________________
Ending Salary: _________________________
Job Title: _________________________________ Supervisor: __________________________________
Work Performed: ________________________________________________________________________
______________________________________________________________________________________
3. Employer: _________________________________Dates Employed: From________To____________
Address: ______________________________________________________________________________
Telephone Number(s):__________________________________ Starting Salary: ____________________
Ending Salary: _________________________
Job Title: _________________________________ Supervisor: __________________________________
Work Performed: ________________________________________________________________________
______________________________________________________________________________________
4. Employer: _________________________________Dates Employed: From________To____________
Address: ______________________________________________________________________________
Telephone Number(s):__________________________________ Starting Salary: ____________________
Ending Salary: _________________________
Job Title: _________________________________ Supervisor: __________________________________
Work Performed: ________________________________________________________________________
______________________________________________________________________________________
If you need additional space, please continue on a separate sheet of paper.
If there are any gaps in your employment, please explain:
______________________________________________________________________________________
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List professional, trade, business or civic activities and offices held which you believe may relate to your qualifications for which you are making application.
______________________________________________________________________________________
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APPLICANT’S STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. I understand that if I wish to be considered for employment beyond this time period, I should inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the Village of Chapin is of an “at will” nature, which means that I may resign at any time and the Village may discharge me at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in wring by an authorized official of the Village.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
I understand that the Village requires applicants for employment to take a drug and alcohol screening test as part of the pre-employment physical examination, and that any offer of employment with the Village is conditional upon the results of my test for drugs or alcohol being satisfactory. I further understand that if I am employed with the Village, I will be required to submit to a drug or alcohol test if the Village has a reasonable suspicion that I am under the influence of alcohol or drugs. I agree to execute any documents required of me to release the results of drug and alcohol testing to the Village.
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Signature of Applicant Date
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