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	PLEASE TYPE OR PRINT RESPONSES TO ALL OF THE QUESTIONS
	CONTAINED ON THE ENTIRE APPLICATION FORM
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POSITION SOUGHT:											
NAME:													
Last                              First      	Middle Initial
HOME ADDR`ESS:											
CITY/STATE/ZIP:											
COUNTY:					 HOME PHONE:						
S.S. NUMBER:				  ARE YOU AN ADULT?  YES   NO 
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	EMPLOYMENT HISTORY AND WORK EXPERIENCE
IN THIS SECTION, LIST ALL EMPLOYMENT HISTORY AND WORK EXPERIENCE IN DATE ORDER, INCLUDING MILITARY EXPERIENCE.  BEGIN WITH YOUR CURRENT EMPLOYER.  USE ADDITIONAL PAPER IF NECESSARY.  FAILURE TO INCLUDE ALL EMPLOYMENT MAY BE GROUNDS FOR DISQUALIFICATION.
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CURRENT EMPLOYER:											
    (Enter "None" if unemployed)
MAY WE CONTACT YOUR CURRENT EMPLOYER PRIOR TO EMPLOYMENT?
YES   NO     
ADDRESS:												
PHONE NUMBER:											
DATES EMPLOYED:					 TO:						
JOB TITLE:												
SUPERVISOR’S NAME:											
BEGINNING SALARY:           	 PER          CURRENT SALARY:           	 PER        
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:															
													
WHY DO YOU WANT TO LEAVE?									
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PREVIOUS EMPLOYER:										
ADDRESS:												
PHONE NUMBER:											
DATES EMPLOYED:					 TO:						
JOB TITLE:												
SUPERVISOR’S NAME:											
BEGINNING SALARY:          	  PER          CURRENT SALARY:           	 PER        
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:															
													
WHY DID YOU LEAVE?										
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PREVIOUS EMPLOYER:										
ADDRESS:												
PHONE NUMBER:											
DATES EMPLOYED:					 TO:						
JOB TITLE:												
SUPERVISOR’S NAME:											
BEGINNING SALARY:           	 PER          CURRENT SALARY:           	 PER        
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:															
													
WHY DID YOU LEAVE?										
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PREVIOUS EMPLOYER:										
ADDRESS:												
PHONE NUMBER:											
DATES EMPLOYED:					 TO:						
JOB TITLE:												
SUPERVISOR’S NAME:											
BEGINNING SALARY:           	 PER          CURRENT SALARY:           	 PER        
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:															
													
WHY DID YOU LEAVE?										
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PREVIOUS EMPLOYER:										
ADDRESS:												
PHONE NUMBER:											
DATES EMPLOYED:					 TO:						
JOB TITLE:												
SUPERVISOR’S NAME:											
BEGINNING SALARY:           	 PER          CURRENT SALARY:           	 PER        
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:															
													
WHY DID YOU LEAVE?										
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IF YOU NEED TO LIST ANY ADDITIONAL PREVIOUS EMPLOYERS, PLEASE USE A BLANK SHEET OF PAPER TO DO SO.
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	EDUCATION AND TRAINING
THIS SECTION IS INTENDED TO GIVE THE EMPLOYER INFORMATION ABOUT THE EDUCATION AND TRAINING THAT THE APPLICANT HAS COMPLETED, AND TO DEMONSTRATE THE SKILLS, KNOWLEDGE, AND ABILITIES OF THE APPLICANT TO PERFORM THE JOB DUTIES OF THE POSITION.
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HIGH SCHOOL ATTENDED:										
ADDRESS:												
DID YOU GRADUATE?		 HIGH SCHOOL EQUIVALENT?						
COURSES PERTAINING TO JOB APPLIED FOR:								
													
ACTIVITIES, AWARDS, SPORTS, ETC.:									

COLLEGE OR TRADE SCHOOL ATTENDED:								
ADDRESS:												
DID YOU GRADUATE?		 DEGREE:								
COURSES PERTAINING TO JOB APPLIED FOR:								
													
ACTIVITIES, AWARDS, SPORTS, ETC.:									
													
GRADUATE SCHOOL(S) ATTENDED:									
													
ADDRESS:												
DID YOU GRADUATE?		 DEGREE:								
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PLEASE USE THE FOLLOWING SPACE TO PROVIDE ANY FURTHER INFORMATION ON TRAINING, EDUCATION, SKILLS, ABILITIES, HOBBIES, VOLUNTEER WORK, ETC., THAT YOU POSSESS OR HAVE EXPERIENCED THAT MAY BE HELPFUL IN THE EVALUATION OF YOUR APPLICATION.
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	PERSONAL INFORMATION
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DO YOU HAVE ANY COMMITMENTS (I.E., SECOND JOB, SCHOOL, ETC.?) WHICH MIGHT INTERFERE WITH, OR ADVERSELY AFFECT, YOUR EMPLOYMENT SHOULD WE SELECT YOU FOR A POSITION?  YES  NO 
IF YES, PLEASE EXPLAIN:										
													
HAVE YOU EVER BEEN CONVICTED OF A FELONY?  YES  NO 
IF YES, PLEASE EXPLAIN:										
													
(THE EMPLOYER WILL ONLY CONSIDER SPECIFIC CRIMES RELATED TO QUALIFICATIONS FOR POSITIONS APPLIED FOR.)
DO YOU POSSESS A VALID DRIVERS LICENSE?  YES  NO 
IF NO, CAN YOU OBTAIN ONE PRIOR TO EMPLOYMENT?  YES  NO 
ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?  YES  NO 
ARE YOU RELATED TO ANYONE THAT IS CURRENTLY EMPLOYED BY THE VILLAGE OF MECHANICSBURG?   YES  NO 
PLEASE LIST THREE REFERENCES WHO ARE NOT RELATED TO YOU THAT YOU HAVE KNOWN AT LEAST ONE YEAR:
NAME:													
PHONE:				 ADDRESS:							
													
NAME:													
PHONE:				 ADDRESS:							
													
NAME:													
PHONE:				 ADDRESS:							
													
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PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY.  INDICATE YOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH PARAGRAPH.  IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE INITIALING THE PARAGRAPH.
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1.	I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary.  I understand and accept that this may include drug, alcohol or substance abuse testing.	   	     Initials:_____

2.	If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be required to work evening shifts or night shifts, including weekends and be on call and work mandatory overtime hours.						   	    Initials:_____

3.	I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration.  I further understand and accept that if I am employed by the Village of Mechanicsburg, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.								   			      Initials:_____

4.	I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees.  I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer’s employees do not have a past record of unlawful activities.  Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity.						  	    Initials:_____

5.	I hereby authorize the employers, schools and personal references named in this application to provide information regarding me to the employer.  I further authorize the release of personnel, academic and other records to the employer.								    Initials:_____

6.	READ CAREFULLY BEFORE INITIALING
	"I agree that any claim or lawsuit relating to my service with the Village of Mechanicsburg or any of its subsidiaries must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit.  I waive any statute of limitations to the contrary."	    Initials:_____

I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.  I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION.  I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINAT ION FOLLOWING EMPLOYMENT.  I RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE.

 (Applicant’s Signature)		(Date)

 (Notarized by)		(Date)

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EEO DATA: VOLUNTARY DISCLOSURE FORM

Regulations of the Equal Employment Opportunity Commission (EEOC) require employers to compile data regarding the nature and make-up of their work forces in order to further the goals of Title VII of the Civil Rights Act of 1964, as amended.  Your responses to the following questions will help the employer comply with this requirement.  Completion of this questionnaire is entirely voluntary on your part.  Should you opt to complete the questionnaire, your response will be used by the employer solely for the purposes of preparing the reports required by the EEOC.  Your response will be kept confidential, and will play no part in the employers evaluation of your employment performance or status, or your treatment as an employee.  The completed questionnaire will be kept separate from your personnel file.

NAME:							
AGE:							
SEX: 							
RACIAL AND ETHNIC CATEGORIES:
  White (not of Hispanic origin)
            Black (not of Hispanic origin)
  Hispanic
  Asian or Pacific Islander
  American Indian or Alaska Native

DO NOT WRITE BELOW THIS LINE

HIRED:	Yes____   No____ POSITION				

DEPT.		  SALARY/WAGE			

DATE REPORTING TO WORK	 SHIFT