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Personal Information

Notice
By filling out this application, you are authorizing the Town to contact your former or current employers (unless you specifically indicate they can’t be contacted) or other references, as well as any educational institutions listed. All of them are authorized to release any information they may have about you; you agree to release the Town and its employees, as well as all references, from any liability which may result or be claimed because of the information provided (or because of the fact that any information was provided). You further agree to defend and hold harmless the Town of Pinetop-Lakeside and any references or educational institutions from any claims, demands, lawsuits, judgments, or other liability relating to the information provided.
Position Applied For*
Department*
Select the department you're applying for:
Applicant's Name*
Mailing Address*
Phone Number*
Message Phone
Email Address
Upload Resume (Optional)
Are you over 18 years of age?*
1. Yes
2. No
Are you legally eligible to work in the United States?*
1. Yes
2. No
3. Other
If other, please explain.
Types of employment you will accept:*
Check all that apply.
1. Regular Full-Time
2. Regular Part-Time
3. Temporary Full-Time
1. Temporary Part-Time
2. Temporary / On-Call
Which shifts can you work?*
Check all that apply.
1. Days
2. Evenings
1. Nights
2. Rotating
How did you learn of this position?
Are you a U.S. Citizen, or do you have the legal right to remain permanently in the U.S.?*
1. Yes
2. No
If you are required to drive a Town vehicle, do you possess a valid Arizona driver's license?*
1. Yes
2. No
Have you ever worked for the Town of Pinetop-Lakeside before?*
1. Yes
2. No
If yes, when?
Are any of your relatives, either by blood or by marriage, currently employed by the Town of Pinetop-Lakeside?*
1. Yes
2. No
Who? What position do they hold?
Have you ever been discharged, or requested or forced to resign from any position?*
1. Yes
2. No
If yes, please explain.
Do you have any reason to believe you will be discharged or requested to resign from your current position within the next thirty days?*
1. Yes
2. No
If yes, please explain.
Have you ever served in the Armed Forces?*
1. Yes
2. No
Which branch?
When?
Are you eligible to be registered for the Selective Service?*
1. Yes
2. No
Have you registered for the Selective Service?
1. Yes
2. No
3. Other
If other, please explain.
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Education

Education
Did you receive a high school diploma?*
1. Yes
2. No
Name of School
Date Received
Date Received
Have you attended a college or university?*
1. Yes
2. No
List all colleges or universities attended, years of attendance, and number of credits earned.
Have you attended a trade, technical, business, or other type of school?*
1. Yes
2. No
When?
Types of Courses Studied
List any licenses, trade or professional registrations.
List any honors, awards, or fellowships received.
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Employment History

References

References
List two references who have known you for at least five years, and one person who lives in your immediate neighborhood.
1st Reference's Name*
1st Reference's Address*
1st Reference's Phone Number*
1st Reference's Email Address
2nd Reference's Name*
2nd Reference's Address*
2nd Reference's Phone Number*
2nd Reference's Email Address
3rd Reference's Name*
3rd Reference's Address*
3rd Reference's Phone Number*
3rd Reference's Email Address
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Additional Comments & Signature

Do you have any additional comments regarding your application?
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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