Human Resources Department
58 Opera House Square
Claremont, NH 03743
Application for Employment
NOTE: If you will require special accommodations in order to apply for this position, please notify the Human
Resources Department
Please Print (in blue or black ink) or Type
Date:_____________________________ Name:_________________________________________________________
PERSONAL
Positions(s) applied for:____________________________________________________________________________
Availability:
Full-time_____
Part-time_____
Seasonal_____
Full Name:__________________________________________ Social Security # (Optional):_______________________
Street Address:__________________________________________________ Home Phone:_______________________
Mailing Address:_________________________________________________ Work Phone:_______________________
City:__________________________________________ State: _____________________ Zip:____________________
Have you ever been employed with us before?
Yes_____ (if yes, provide details below
) No_____
Title of position held:____________________________________________ Termination Date:_____________________
Reason for leaving:_________________________________________________________________________________
Are you a retired or disabled retiree of the New Hampshire Retirement System ______ YES ______NO
List any relative(s) who currently works for the City of Claremont:
Name:_________________________________ Department:______________________ Relationship:_______________
Name:_________________________________ Department:______________________ Relationship:_______________
Name:_________________________________ Department:______________________ Relationship:_______________
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes_____
No_____
Are you a citizen of the United States?
Yes_____
No_____
If no, can you provide proof that you are eligible to work in the United States in accordance with the Immigration
Reform and Control Act?
Yes_____
No_____
EDUCATION
Did you receive a high school Diploma or HiSET?
Yes_____
No_____
Highest grade completed:
5____ 6____ 7____ 8____ 9____ 10____ 11____ 12____ College: 1____ 2____ 3____ 4____ 5____ 6____
School (name, city, state)
Dates
Degree
Major/Minor
From: ______________
______________________________________
To: ________________ ______________ _______________________
High School
From: ______________
______________________________________
To: ________________ ______________ _______________________
Undergraduate College/University
From: ______________
______________________________________
To:________________ ______________ _______________________
Graduate/Professional College/University
From: ______________
______________________________________
Other Education i.e. Technical, Business
To: ________________ ______________ ______________________