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APPLICATION FOR EMPLOYMENT
City of Washington 405 Jefferson Street
Washington, MO 63090 Attn: Human Resources
We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.
(PLEASE PRINT) Position(s) Appli ed For Date of Application
How Diel You Learn About Us?
D Advertisement D Relative D Inquiry
D Employment Agency D Friend D Other
Last Name First Name Middle Name
Addr·ess Nu111ber Streel Ci1y Slate Zip Code
Telephone Number(s) Social Security Number (Voluntary)
I I
Best time to contact you at home is: AM
----PM
If you are under 18 years of age, can you provide required proof of your eligibility to work? D Yes D No
Have you ever fi led an application with us before? .. .... .... .. .. ... .. ... ... ... ...... ... ... ... ... ...... ... ... .. . D Yes D No
.... ... .......... ...... ... ...... ... ..... .......... ... .... .... .. ..... ................... .. If Yes, give date ______ _
Have you ever been employed with us before? ....... .. ....... .. .. .... ..................... ... ..................... D Yes
If Yes, give date ______ _
Do any of your friends or relatives, other than spouse, work here? .. ..... ............................ D Yes
Are you currently employed?........................................... .. ................. ..... .. .......... .. ....... ......... D Yes
May we contact your present employer?............... ........ ....................... .. ................... .. ..... .... D Yes
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or imm.igration status will be required upon employment. .. .. . . . .. . D Yes
Date available for work __ / __ / __ What is your desired salary range? _____ _
Are you available to work: (please indicate 1 2 3 shift)
D No
D No
D No
D No
D No
D Full-Time
D Part-Time
D Temporary
(please indicate Mornings Afternoon Evenings)
(please indicate dates available _!_!_ - _ !_ !_ )
Are you currently on "lay-off" status and subject to recall? ....... ... ... ... ..................... ........... D Yes
Can you travel if a job requires it? ............................................ .. .... .. .................................... D Yes
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
D No
D No
EDUCATION
Describe am s1wcializcd training, apprcnlil'l'ship . skills and l'\ lra-cu, ri u tlar ac ti\ ilil·s .
Ocscrihl' ~111\ job-related lr;1i11i11 1' I l'l'l' i\l·d i11 tliL· l 'nitl'd St;itL's 111ilitan .
EMPLOYMENT EXPERIENCE
Start with your present or last job. Inclu de 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.
1.
2.
3.
4.
Employer
Address
Telephone Number (s)
Job Title Supervisor
Reason for Leaving
Employer
Address
Telephone Number(s)
Job Title Supervisor
Reason for Leaving
Employer
Address
Telephone Number(s)
Job Title Supervisor
Reason for Leaving
Employer
Address
Telephone Number(s)
Job Title Supervisor
Reason for Leaving
If you need additional space, please continue on a separate sheet of paper.
List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other
protected status:
ADDITIONAL INFORMATION
Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
SPECIALIZED SKILLS ( CHECK SKILLS/EQUIPMENT OPERATED)
_Terminal _ Spreadsheet
_ Word Processing
_ Shorthand
Production/Mobile Machinery (list) Other (list)
PC/MAC
_Typewriter
WPM WPM
State anv additional i11for111atio11 you feel nun· be /,e/pfitl to U8 in co11sideri11f!, your applica I ion.
Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HA VE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPL YING.
Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation? __ YES __ NO
REFERENCES
(Name) Phone#
(Address)
2. _______________ _ _ ___ _ ( _ _ ) ----------(Name) Phone#
(Address)
3. _ ______ ___ _ _ ______ _ __ ( __ ) - - --------(Name) Phone #
(Address)
APPLICANT'S STATEMENT
I certify that answers given herein are tn1e and complete.
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. Any applicant wishing to be considered for employment beyond this time period 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 this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.
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.
Signature of Applicant Date
FOR PERSONNEL DEPARTMENT llSF ONLY
Arrange Interview D Yes D No
Remarks ------------- - --- --- ----- ----- ----
INTERVI EWER DATE
Employed D Yes D No Date of Employment ____ __________ _
Hourly Rate/ Job Title _ _ _ _ ___ Salary _ __ _ Department _ _ _ ________ _
NAM E AND T ITLE DATE
This Application For Employment is sold for general use throughout the United Sta tes. Amsterda m Printing assum es no responsi bili ty for the use of said form or any questions which, when asked by the employer of the job applicant , may vio la te State and/or Federal Law.
q..\NT~ 4. IN O
Cl.SJ,., Rev 6/16 Re-order Form #23960 (23962 imprinted) ([)copy1ight 20 17 Amsterda m Print ing, Ams terdam , N.Y. 120 I 0 Toll Free 1 ·866A66· 1438 or on linc www.ams tcrdamforms.com Amsterdam·
CERTIFICATE OF APPLICANT
AUTHORIZATION FOR RELEASE OF INFORMATION
(READ CAREFULLY BEFORE SIGNING)
I, (Print Full Name) ____________ hereby certify that all statements made
on or in connection with this application are true and complete to the best of my knowledge
and belief. I understand and agree that any mis-statements or omission of material facts will
cause forfeiture on my part of all rights to employment with the City of Washington, Missouri.
I hereby authorize all law enforcement agencies, the Veteran Administration, U.S. Army, U.S.
Air Force, all military agencies, tax bureaus, credit bureaus, schools and universities, to furnish
the holder of this release with all and any available information regarding me in order that he
may determine my suitability for employment.
I authorize the holder of this release to make inquiry of my present and past employers
regarding my character, integrity, and reputation.
I authorize the release of any and all information regarding my employment, credit or any
other information, where personal or otherwise, that may or may not be in their records, and release said company of person from all liability for any damage whatsoever that my issue
from furnishing such information to the holder of this release.
A copy of this authorization will be considered as effective and valid as the original.
Driver's License# ----------Date of Birth ------------Are you related to any City of Washington employee or elected official? OYes D No
If yes, how are you related?----------------------
Signature of Applicant Date
DRIVER QUALIFICATIONS
Inspection of License Information
A. Driver's License Classification:
B. Endorsements:
C. Restriction Code
(enter, if this is the first review;
Check against existing license
To determine accuracy):
D. License Number:
E. Expiration Date:
F. Address:
Circle Those That Apply
AB CEFHM
BCHMNPTX
AGCDFIJLOUWZ
Number & Street
City State Zip Code
If any changes in the information above affect: classification, expiration date or restriction
code; and, have an impact on the driver's ability to meet City driving requirements, driver
should notify Human Resources of the change immediately and driver should not be allowed
to operate City vehicles.
Please submit on a separate sheet of paper and attach a statement detailing any moving traffic
convictions.
Signature of Employee---------------------
Type of Vehicle Qualified for: __________________ _
DRUG SCREENING AND CRIMINAL RECORD CHECK
Dear Applicant:
The City of Washington has adopted a Drug Screening and Criminal Record Check
Process for all new hires.
All Applicants with the City of Washington must sign below AND, if under the age
of 18 years, have a Parent/Guardian sign this form for parental consent for the drug
screening and criminal record check.
Only the applicants offered the positions will be required to submit to a drug
screening and criminal record check.
The position will be contingent upon receiving a negative result from the drug
screening and criminal record check. This consent also allows the release of the test
results to an authorized city representative for review.
Job Applicant Signature Date
Parent/Guardian Signature Date
*FORM MUST BE RETURNED WITH YOUR APPLICATION*
REQUEST FOR CRIMINAL RECORD CHECK
GENERAL INFORMATION APPLICANT'S LAST NAME FIRST MIDDLE JR/SR
MAIDEN L ALIAS LAST NAME FIRST MIDDLE JR/SR
ADDRESS STREET- P.O. BOX CITY STATE ZIP CODE
SEX DATE OF BIRTH SOCIAL SECURITY NUMBER RACE
D MALE (MM/DD/YYYY)
D BLACK D INDIAN D OTH ER
D FEMALE D WHITE D ASIAN
City of Washington Job Description
Maintenance Worker I (Laborer)
Status: Full-time-Seasonal
FLSA Status: Non-exempt
Department: Streets and Sanitation
Immediate Supervisor: Street Foreman and Street and Sanitation
Superintendent
General Purpose of Position
Completes maintenance of public facilities and works on capital projects as assigned
Major Duties and Responsibilities (Essential Functions)
Maintains City grounds and related properties Mows, weed-eats, and seeds grass
Performs raking and leaf pick-up
Mulches landscape
Picks up loose trash and empties trash receptacles
Trims trees and disposes of brush properly
Maintains City buildings and facilities Cleans, maintains and paints buildings
Cleans restrooms and repairs fixtures when needed
Checks for vandalism or broken items at facilities
Changes light bulbs, using heavy equipment when necessary
Performs other necessary cleaning or maintenance duties
Maintains City equipment Performs seasonal maintenance
Replaces equipment belts
Changes oil in equipment
Replaces equipment wheels and tires as needed
Performs other duties related to departmental activities Installs chain link fences
Serves as Refuse Collector when needed
Assists with concrete work and laying asphalt
Backfill sinkholes and other depressions
Repair and replace signs as needed
Bush hog drainage ditches and other areas
Complete general street maintenance activities
Run snow removal routes and assist with other snow removal activities
Keeps record of mileage/hours for vehicles and equipment
Maintains appropriate logs, including hours used, and maintenance reports for all equipment
Schedules and completes regular maintenance for equipment
Performs needed maintenance such as: oil changes, checks tires, lights, and general engine maintenance
Follows all work zone safety guidelines, wearing high visibility apparel, differentiate the worker from vehicles
using signs, drums
Completes construction projects as assigned Builds wood structures from frame-in to finishing carpentry
Performs metal work using welding techniques
Builds various constructs using concrete, including retaining walls, handicap ramps, etc.
Completes basic plumbing and electrical work
Marginal Duties and Responsibilities
Performs other duties as directed
Working Conditions
The work environment characteristics described here are representative of those an employee encounters while
performing the essential functions of this position. Reasonable accommodations may be made to enable individuals
with disabilities to perform the essential functions.
While performing the duties of this position, the employee is exposed more than two thirds of the time to conditions
such moving mechanical parts; fumes, airborne particles, cramped spaces; toxic or caustic chemicals, debris, and
outside weather conditions. The employee may also be exposed to high, precarious places, and vibration. The
employee may also be exposed to risk of electrical shock. The noise level in the work environment is usually loud.
This position may be called out 24 hours a day or rotate being on call, including weekends and holidays.
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully
perform the essential functions of this position. Reasonable accommodations may be made to enable individuals
with disabilities to perform the essential functions.
While performing the duties of this position, the employee is regularly required to stand and walk, use hands to
finger, handle, hold or grip, or feel; reach with hands and arms and talk or hear. The employee is occasionally
required to sit, run, climb or balance and stoop, kneel, crouch, or crawl. Lifting, moving, pushing or pulling, raking
or shoveling up to 25 pounds does generally occur. Specific vision abilities required by this job include close vision,
color vision, depth perception, distance vision and ability to adjust focus.
Required Education and Experience
High school diploma or its equivalent. One to three months related experience and/or training; or equivalent
combination of education and experience. Must be able to read and write in English.
Preferred Education and Experience
Three to six months related experience and/or training; or equivalent combination of education and experience.
One year of general maintenance experience is desirable. An equivalent combination of education and experience
will be considered.
Licenses and Certifications
The person in this position must obtain a valid Class B Commercial Driver’s Missouri driver’s license within one
year of employment.
Knowledge, Skills and Abilities
Knowledge Knowledge of proper maintenance, repair and use of equipment assigned to area of responsibility such as
mowers, weed eaters, chain saws, loader, tandem axle dump truck.
Knowledge of city’s refuse collections routes and most efficient ways to run them
Knowledge of safety regulations and rules regarding compacting garbage trucks, traffic
Knowledge of layout of city streets
Knowledge of federal and state statutes concerning the work of the department
Knowledge of principles and processes for providing customer and personal services. This includes identifying
customer needs, meeting standards for service and customer satisfaction
Skills and Abilities Ability to speak effectively before groups of customers or employees of organization, effective communication
skills orally and in writing
Ability to write routine reports and correspondence
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and
procedure manuals
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages,
area, circumference, and volume
Ability to apply concepts of basic algebra and geometry
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram
form
Ability to deal with problems involving several concrete variables in standardized situations
Ability to prioritize daily work flow
Ability to meet specified or required deadlines
Ability to maintain accurate records
Ability to attend to duties reliably and predictably
Ability to follow departmental and City policies and procedures
Ability to read and interpret engineering grades and slopes
Knowledge of proper maintenance, repair and use of equipment assigned to area of responsibility such as
mowers, weed eaters, chain saws, loader, tandem axle dump truck. Ability to use various types of equipment,
including mowers, saws, weed eaters.
Ability to use various types of equipment, including weed eaters, mowers, saws
Ability to attend to safety of self and customers, identify hazardous situations
Supervision None
Signature and Approval
________________________________ __________________
Employee Date
________________________________ __________________
Department Director Date
________________________________ __________________
Human Resources Date
________________________________ __________________
City Administration Date
The above statements are intended to describe the general nature and level of work being performed by individuals
assigned to this job. They are not intended to be an exhaustive list of all essential functions, marginal functions,
responsibilities, duties, and skills required of personnel so classified in this position.
Recommended