APPLICATION FOR EMPLOYMENT

City of Washington 405 Jeffaraon 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) Applied For Date of Application

How Did You Learn About Us?

D Advertisement D Relative D Inquiry D Employment Agency D Friend D Other

Last Name First Name Middle Name

Address Number Street City State Zip Code

Telephone Number(s) E-mail 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 filed 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 lawfully authorized to work in the United States? ..................... .. .......................... 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

o No

D No

D No

o 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 specialized training, apprenticeship, skills and extra-curricular acti\ ities.

- -

Describe any job-related training received in the United States military.

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include 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. Employer Dates Employed JFrom Jro

Address Work Performed --- -

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

2. Employer Dates Employed IFrom lro

3.

4 .

Address Work Performed

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

Employer Dates Employed jFrom Ira

Address Work Performed

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

Employer Dates Employed !From lro

Address Work Performed c-

Telephone Number(s)

Job Title I 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 acquin.:d from employment or other experience.

SPECIALIZED SKILLS

_Terminal

_PC/MAC

_ Typewriter

WPM

( CHECK SKILLS/EQUIPMENT OPERATED)

_Spreadsheet

_Word Processing

_ Shorthand

WPM

Production/Mobile Machinery (list) Other (list)

State any additional information you feel may be /,e/p/i,/ to us in considering your application.

-

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

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 true 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

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview D Yes D No

Remarks --- --- - - -----------------

Date

INTERVIEWER DATE

Employed D Yes D No Date of Employment _ _________ ____ _

Hourly Rate/ Job Title _______ Salary ___ _ Department ________ __ _

NAME AND TITLE DATE

This Application For Employment is sold for general use throughou t the United States . Amsterdam Printing assumes no responsibility for ~he use of said form or any questions which , when asked by the employer of the job applicant, may viola te Sta te and/or Federal Law.

Rev 10/19 Re-order Form #23960 (23962 impri nted) <!:>co pyright 2020 Amsterda m Pri nting, Amsterdam, N.Y. 120 I 0 Toll Free 1-866-466- 1438 or online www.amsterdamforms.com l'.msterdam ·

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FOR PERSONNEL DEPARTMENT USE ONLY

Position(s) Applied For Is Open: n Yes CJ No

Position(s) Considered For:

Date __________ _

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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.

I give consent to contact me via email at:

Email address ______________________________________________

Are you related to any City of Washington employee or elected official? ☐Yes ☐ No

If yes, state who and how are you related? __________________________________________________

_________________________________________ __________________________

Signature of Applicant Date

DRIVER QUALIFICATIONS

Inspection of License Information Circle Those That Apply

A. Driver’s License Classification: A B C E F H M

B. Endorsements: B C H M N P T

C. Restriction Code A G C D F I J L O U W Z

D. License Number: ___________________________________

E. Expiration Date: ___________________________________

F. Address: ___________________________________

Number & Street

City State Zip Code

If there are any changes to the driver’s classification, expiration date or restriction code, which

may impact the driver’s ability to meet City driving requirements, the driver must notify

Human Resources immediately and will not be allowed to operate City vehicles until resolved.

All moving violations must be disclosed and attached to this document.

Type of Vehicle(s) Driver is qualified to operate _____________________________________

____________________________________________________________________________

Printed Name: _____________________________________________

Signature: __________________________________________________

Drug Screening and Criminal Record Check Consent Form

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 INFORMATIONAPPLICANT’S LAST NAME FIRST MIDDLE JR/SR

MAIDEN / ALIAS LAST NAME FIRST MIDDLE JR/SR

ADDRESS STREET – P.O. BOX CITY STATE ZIP CODE

SEX MALE FEMALE

DATE OF BIRTH(MM/DD/YYYY)

SOCIAL SECURITY NUMBER RACE BLACK INDIAN OTHER WHITE ASIAN

This Organization Participates in E-Verify

This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. If E-Verify cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment. Employers can only use E-Verify once you have accepted a job offer and completed the Form I-9.

E-Verify Works for Everyone

For more information on E-Verify, or if you believe that your employer has violated its E-Verify responsibilities,

please contact DHS.

Esta Organización Participa en E-Verify

Este empleador participa en E-Verify y proporcionará al gobierno federal la información de su Formulario I-9 para confirmar que usted está autorizado para trabajar en los EE.UU.. Si E-Verify no puede confirmar que usted está autorizado para trabajar, este empleador está requerido a darle instrucciones por escrito y una oportunidad de contactar al Departamento de Seguridad Nacional (DHS) o a la Administración del Seguro Social (SSA) para que pueda empezar a resolver el problema antes de que el empleador pueda tomar cualquier acción en su contra, incluyendo la terminación de su empleo. Los empleadores sólo pueden utilizar E-Verify una vez que usted haya aceptado una oferta de trabajo y completado el Formulario I-9.

E-Verify Funciona Para Todos

Para más información sobre E-Verify, o si usted cree que su empleador ha violado sus responsabilidades de E-Verify, por

favor contacte a DHS.

888-897-7781

dhs.gov/e-verify

English / Spanish Poster

City of Washington Job Description Equipment Operator

Status: Full-time FLSA Status: Non-exempt Department: Landfill Immediate Supervisor: Landfill Foreman General Purpose of Position Completes maintenance of public landfill, compost site, and other projects using heavy equipment Major Duties and Responsibilities (Essential Functions) Uses heavy equipment to complete various departmental activities • Checks equipment before each use, performing daily inspections, lubricating and preparing equipment • Determines when equipment needs to be used • Operates equipment according to safety guidelines • Prepares for maintenance when it is necessary Operates the scraper, compactor, dump truck and other large equipment • Safely transports materials to and from the site for cover and grading of site • Push and compact trash and debris into pit while following safety guidelines aware of traffic and weather • Direct traffic flow • Answer customer questions about what materials can be brought in and what can’t be brought into site • Maintain roads for moving materials, performing snow and ice removal, reinforcing portions where muddy • Picks up trash • Repairs fencing • Operates other equipment as required Maintains City equipment • Performs seasonal maintenance • Sharpens mowing blades • Replaces equipment belts • Changes oil in equipment • Replaces equipment wheels and tires as needed Marginal Duties and Responsibilities • Operate scale house, greeting and weighing customers, answering questions, receipting and recording fees • Performs snow and ice removal • 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, poor ventilation, cramped spaces; toxic or caustic chemicals, trash, 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 its equivalent. Two to three years related experience and/or training; or an equivalent combination of education and experience. Preferred Education and Experience Four to five years related experience and/or training; or a bachelor’s degree from a college or university; or an equivalent combination of education and experience. Licenses and Certifications The person in this position must have a valid Class B commercial driver’s license with airbrakes certification. Other certifications, such as water operator or wastewater treatment operator certification, are preferred. Knowledge, Skills and Abilities Knowledge • Knowledge of proper maintenance, repair and use of heavy equipment, including scraper, compactor, tandem

axle dump truck and skid loader • Knowledge of proper installation, maintenance and repair of streets, sidewalks, curb and gutter, storm drains,

signs and traffic signals • Knowledge of basic engineering for determining and digging grade and slope • Knowledge of layout of city streets • Knowledge of turf management principles and practices including seeding, sod, fertilizing • 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 • Ability to use various types of heavy equipment, including aerial bucket lift truck, tandem axle dump truck and

skid loader, street sweeper, backhoe, tamper, refuse trucks, compactor • Ability to use various types of equipment, including weed eaters, blowers, jackhammers, 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.