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	APPLICATION FOR EMPLOYMENT	AN EQUAL
	City of Rocky Mount, NC	AN EQUAL
	City of Rocky Mount, NC	OPPORTUNITY EMPLOYER

To Applicants: We appreciate your interest in our organization and assure you that we will carefully consider your qualifications. Please complete the application form thoroughly and accurately. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications.

*If you have a disability, and you need special assistance in order to complete the application process (including written examinations, oral interviews, filling out application forms, etc.) please see the receptionist.

PERSONAL

1.Position applied for ________________________________________________ Date of Application _____________

2.Name _______________________________________________________

(LastFirstMiddle)

3. Mailing Address _________________________________________________________________________________

Street & No. or RFD

City

County

State

Zip Code

Do you reside in the Rocky Mount City Limits

YES

Telephone:

Home ______________

If none, where can you be reached by phone?__________________________

Business ______________

Resident’s Name ____________________________________________

Are you:

Under 18

Over 18

Do you want to work

Full-Time

or Part-Time?

Specify days and hours if part-time ______________

Are you willing and able to work rotating shifts?

_______

__________________________________________

8.How did you learn of this opening? __________________________________________________________________

9.Have you worked for the City before? __________ If yes, when and what position did you hold? ________________

________________________________________________________________________________________________

10.List any relatives working for the City ________________________________________________________

_________________________________________________________________________________________________

11.If hired, on what date will you be ready to start work? ___________________________________________________

12. Have you ever been convicted of a crime, including misdemeanors and summary offenses? No		Yes

Please list offense(s) and date(s) of conviction(s) _________________________________________________________

_________________________________________________________________________________________________

Note: You may omit any other offense committed before your 16th birthday which was finally heard in a juvenile court or under a youth offender law.

13.Do you have a valid driver’s license? _________ Driver’s License Number & Type/State _______________________

List all traffic convictions, location & date of all traffic convictions _____________________________________________

_________________________________________________________________________________________________

14.Clerical Skills: Typing __________________ Shorthand:______ ______________ Other: ____________________

_________________________________________________________________________________________________

15.Are there any other experiences, skills, or qualifications which you feel would be important to include?

_________________________________________________________________________________________________

MILITARY HISTORY

Have you ever served in the armed forces? YES	NO		If yes, what branch? _____________________

Dates of duty: From ______________ To ______________		Any current reserves or military obligation? __________

FOR MALES AGE 18 THROUGH 25 ONLY

Males who are 18 through 25 are required to register with the Federal Government in accordance with the Military Selective Service Act. State law prohibits local government from employing anyone who has not complied with this requirement.

Please indicate if you have registered for Selective Service: ______YES ______NO

EDUCATIONAL BACKGROUND

TYPE OF SCHOOL

Grammar or Grade

High School

College

Post Graduate

Business or Trade

Technical

Other

NAME & ADDRESS

HOW MANY YEARS

ATTENDED?

DATE

GRADUATED

COURSE OR MAJOR

If you did not graduate from High School, did you obtain your GED equivalency?	YES

WORK HISTORY

List the jobs that you have held, beginning with your last or present employer. Include part-time jobs, military service, and/or periods of unemployment in the proper sequence. Failure to give complete information may result in rejection of your application. If more space is needed, use a continuation sheet.

Dates

From

Number Hrs./

Week

Job Title

Dates

From

Number Hrs./

Week

Job Title

Name & Address of Employer	Rate of Pay		Supervisor’s Name	Reason for
Name & Address of Employer	Start	Finish	& Phone Number	Leaving
	Start	Finish	& Phone Number	Leaving

Describe briefly the work you did:

Name & Address of Employer	Rate of Pay		Supervisor’s Name	Reason for
	Start	Finish	& Phone Number	Leaving

Describe briefly the work you did:

Dates

From

Number Hrs./

Week

Job Title

Dates

From

Number Hrs./

Week

Job Title

Name & Address of Employer	Rate of Pay		Supervisor’s Name	Reason for
	Start	Finish	& Phone Number	Leaving

Describe briefly the work you did:

Name & Address of Employer	Rate of Pay		Supervisor’s Name	Reason for
	Start	Finish	& Phone Number	Leaving

Describe briefly the work you did:

May we contact the employers listed above? _________ If not, indicate below which ones you do not wish us to contact.

_________________________________________________________________________________________________

PERSONAL REFERENCES

List three (3) persons who are not related to you who have definite knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors in WORK HISTORY.

Name & Occupation

Address

Phone Number

DECLARATION OF APPLICANT:

I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to questions. I am aware that should an investigation disclose any misrepresentation, omission, or falsification, my application may be rejected, or if already employed, my employment may be terminated.

______________________________________________	___________________________________
APPLICANT’S SIGNATURE	DATE

NOTICE TO APPLICANTS

It is the policy of the City of Rocky Mount not to discriminate on the basis of race, sex, national origin, disability, age, creed, color, or religion in any employment decision.

RETURN APPLICATION TO:

Human Resources Department

City of Rocky Mount

P.O. Drawer 1180

Rocky Mount, NC 27802-1180

Telephone: (252) 972-1186

Fax: (252) 972-1197

Email: jobs@rockymountnc.gov

http://www.rockymountnc.gov

NOTICE TO APPLICANTS

It is the policy of the City of Rocky Mount to ensure that its employees are free from the effects of alcohol and drugs. All applicants selected for emplyment must satisfactorily pass a medical examination which includes a drug screening test. T hose applicants with a confirmed positive test for drugs/alcohol will not be hired.

Mission

The mission of the City of Rocky Mount is to provide courteous and responsive public service of the highest quality and value for the benefit and enjoyment of our community and its citizens.

In accordance with the Americans with Disabilities Act, the City of Rocky Mount

will consider reasonable accomodations if requested.

ONE GOVERNMENT PLAZA	ROCKY MOUNT
POST OFFICE BOX 1180	NORTH CAROLINA 27802-1180

PRE-EMPLOYMENT INFORMATION FORM

Please a nswer the fo llowing questions to he lp us comply with Federal/State equal employment opportunity recordkeeping, reporting, and other legal requirements.

This information w ill n ot be us ed in co nsidering you fo r em ployment and the P re-Employment Information Form will be kept in a confidential file separate from your Application for Employment.

1. N ame:________________________________________________________________________


2.	Birthdate:_________/________/_________			3. S.S.#______________________________
4.	Race/Ethnic Group:	__________White		___________African American
		__________Hispanic		___________American Indian
		__________Other ______________________________________________
5.	Sex: __________Male		___________Female
6.	Marital Status:	__________Single		___________Married
		__________Divorced		___________Widowed

NOTICE TO APPLICANTS

OVERTIME POLICY AND AGREEMENT FOR NON_EXEMPT POSITIONS

Consistent with the provisions contained in the 1985 amendments to the FAIR LABOR STANDARDS ACT, i t is the City’s policy to com pensate non-exempt e mployees for overtime work with compen- satory time off, when possible, in lieu of overtime pay.

If I am e mployed i n a no n-exempt posi tion, I agree to acce pt, at t he d iscretion of the City, either compensatory time off or overtime pay, as appropriate compensation for overtime work that I may be required to perform as an employee of the City of Rocky Mount.

Applicant Signature:______________________________________ Date:________________

DRUGS/ALCOHOL POLICY

It is the policy of the C ity of Rocky M ount to ensure that its employees are free from the effects of alcohol and drugs. All applicants se lected f or em ployment must sati sfactorily pass a m edical examination which includes a drug screening test. Those applicants with a confirmed positive test for drugs/alcohol will not be hired.

Question	Answer
Form Name	Rocky Mount App Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	dmv application online for a job for new rocky mount office, ebc rocky mt app, anization, n-exempt

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