City Of Seymour Employment Application Form General Information Page 2
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1
2Employment History
Most recent experience first – Include ALL employers for the past four years. Explain any gaps in
employment.
1. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
2. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
3. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
4. Company Name:
Telephone:
Address:
Date Started:
Date You Left:
Supervisors Name and Title:
Reason for Leaving:
Wage:
May we contact the employers listed above?
O Yes
O No
Personal References
Please list three individuals who are not related to you, do not live with you, and have known you for three
years.
Name
Address
Telephone Number
Relationship
How long have
you known this
person?
Additional Information
Can you show proof of eligibility to work in the U.S.?
O Yes
O No
If offered employment with the City, federal law will require you, to furnish documents showing you are
eligible to work in the U.S. Individuals who do not furnish these documents cannot work for the City.
I authorize anyone whom request is made to supply the City any information concerning my background in
connection with employment consideration. I hereby release all parties, including but not limited to the
City and my prior employers, from any and all liability for any damage that may result from their
furnishing information concerning me. I understand falsification, misrepresentation, incomplete
information, or omission of facts called for on this application will result in dismissal.
I understand and hereby acknowledge that if I am offered and accept employment with the City, my
employment and compensation may be terminated with or without cause and with or without notice at any
time at the option of the City. I further understand that this application for employment is not a contract of
employment.
Signature:
Date:
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Parent category: Business