Application for Employment

We welcome you as an applicant for employment with the City. Your application will be considered with others in competition for the position in which you are interested. It is the policy and intent of the City of Batavia to provide equal opportunity in employment to all persons. This policy prohibits discrimination because of race, color, religion, national origin, political affiliation, gender, sexual orientation, age, marital status, veteran status, or physical or mental disability. This policy applies to all phases of full, part-time, temporary and seasonal employment.

All information contained in or connected with this application will be considered personal and confidential and used only in conjunction with your possible employment by the City of Batavia. Please furnish us with complete information as outlined in this application. You are encouraged to attach any additional information, which you believe qualifies you for the position for which you are applying. If you have any questions about the status of your application please call Human Resources at (630) 454-2070.

Position(s) Applied For:

Date of Application:

Personal Information

Last Name	First Name	Middle Name
Street Address	City	State	Zip-code
Telephone Number	Email Address
Date available for work:

Work Type

Please indicate the type of employment desired.
Full-Time	Part-Time	Temporary	Summer	Educational Co-op	Internship

Referral Source

Please indicate how you heard about the job you are applying for.
	Community Service Line
	Walk-In
	Employment Agency Name
	Relative's Name
	Newspaper Name
	Periodical Name
	Website
	Other Source

If necessary, best time to call you at home is AM PM

Have you filed an application here before? Yes No
If yes, give position applied for:

Have you ever been employed here before? Yes No
If yes, give dates. From: To:

Is any of your employment data under a different name? Yes No
If yes, state name:

Are you legally eligible for employment in this country? Yes No
(Proof of U.S. Citizenship or Immigration status will be required upon employment.)

Are you on lay-off subject to recall? Yes No

Have you been convicted of a felony? Yes No
(Such conviction may be relevant if job related, but does not bar you from employment.)
If Yes, please explain:

Do you have a valid driver's license? Yes No

Do you have a valid Commercial Driver's License (CDL)? Yes No

Education

Please indicate the last three schools that you have attended.
School Name	Years Completed	Degree or Diploma	GPA/Class Rank	Major	Minor

References

Professional References: Please list the names of three supervisors/co-workers whom you have known for at least one year.
Name	Telephone Number	Years Known	Type
			Business School Personal
			Business School Personal
			Business School Personal

Employment History

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

Employer #1
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #2
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #3
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Employer #4
Employer:	Phone:		Full-Time Part-Time Non-Exempt Exempt
Address:	Dates Employed
	From:	To:	Summarize the nature of the work performed and job responsibilities.
Job Title:	Hourly Rate/Salary
	Starting $ Per Final $ Per
Immediate Supervisor:
Reason for Leaving:
May we contact for Reference? Yes No Later

Comments:

Including an explanation of any gaps in employment.

Skills and Qualifications:

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work for the City.

Please Read Carefully

Please Read Carefully Before Signing: I certify that all the statements in this application are accurate to the best of my knowledge. I understand that any false statements on this application shall be considered sufficient cause for dismissal.

I authorize the City of Batavia to investigate any of the information contained herein, including the contacting of my references. I also authorize the Batavia Police Department to disclose and/or release any information on any conviction listed on file under my name and release the Batavia Police Department from any and all liability for damages for the furnishing of any information concerning me.

If I receive a conditional offer of employment with the City, I agree to submit to a physical examination, which includes a pre-employment drug test, which I will be required to pass before being finally accepted for employment.

I further agree to comply with all the rules and regulations of the City of Batavia now in force or any that may be established.

Signature

I have read the statements above and fully understand and agree. This application will not be accepted unless this box is checked.
Signature of Applicant (type your full name):	Date:

City of Batavia 100 North Island Avenue Batavia, IL USA 60510
Phone: 630-454-2000 Fax: 630-454-2001

The City of Batavia has a regular procedure for reviewing the information on this site, including removing inaccurate
or stale information. Although we do our best, the City disclaims any duty to keep the information therein current.