Job application

Position applying to(Required)
Applicant Name(Required)
First Middle Last
Address(Required)
Street Address Address Line 2 City State ZIP Code
Primary Phone(Required)
Secondary Phone
Email(Required)
How much do you expect for your starting annual salary?
Have you filed an application here before?(Required)
- Yes
- No
Date of previous application(Required)
Have you ever been employed here before?(Required)
- Yes
- No
Date of previous employment (last day)(Required)
Are you currently employed?(Required)
- Yes
- No
May we contact your current employer?(Required)
- Yes
- No
Are you a U.S. citizen or can you establish that you are an authorized worker?(Required)
- Yes
- No
When are you available to start?(Required)
Preferred type of work(Required)
Check all that apply
- Full time
- Part time
- Seasonal
Are you on layoff and subject to recall?(Required)
- Yes
- No
Other than minor traffic violations, have you been convicted of a crime?(Required)
Conviction of a crime will not necessarily disqualify and applicant - the nature of the crime and when the conviction occurred will be considered). You are NOT obligated to disclose sealed or expunged records of conviction or arrest.
- Yes
- No
If yes, please explain:(Required)
Do you have the physical ability to perform all essential duties of the job(s) for which you are applying?(Required)
- Yes
- No
If no, please explain:(Required)
Are there workplace accommodations which would assure better job placement and/or enable you to perform your job to your maximum capability?(Required)
- Yes
- No
If yes, please explain:(Required)
List professional, trade, business or civic activities and offices held:
Exclude those which indicate race, color, religion, sex or national origin.
Reference list(Required)
Please provide name, email and phone number for 3 references. Your references should not be related to you and not a previous employer.
Name Email Phone
Education
Provide information for elementary, high school, college/university, and any graduate or professional education.
School name Grade / years completed Diploma / degree Course of study Honors Received
Describe any specialized training, apprenticeship, skills and extra-curricular activities
Provide any additional information you feel may be helpful to us in considering your employment
Summarize any special skills and qualifications acquired from employment or other experience
Current or most recent employer information
Start with your present or last job. Include military service assignments and volunteer activities.
Name of current (or most recent) employer
Employer's address
Street Address Address Line 2 City State ZIP Code
Employer's phone
Job title
Supervisor's name
First Last
Reason for leaving
Start date
Last day
Starting hourly rate or salary
Final hourly rate or salary
Work performed
Previous employer information
Include military service assignments and volunteer activities.
Name of employer
Employer's address
Street Address Address Line 2 City State ZIP Code
Employer's phone
Job title
Supervisor's name
First Last
Reason for leaving
Start date
Last day
Starting hourly rate or salary
Final hourly rate or salary
Work performed
Previous employer information
Include military service assignments and volunteer activities.
Name of employer
Employer's address
Street Address Address Line 2 City State ZIP Code
Employer's phone
Job title
Supervisor's name
First Last
Reason for leaving
Start date
Last day
Starting hourly rate or salary
Final hourly rate or salary
Work performed
Previous employer information
Include military service assignments and volunteer activities.
Name of employer
Employer's address
Street Address Address Line 2 City State ZIP Code
Employer's phone
Job title
Supervisor's name
First Last
Reason for leaving
Start date
Last day
Starting hourly rate or salary
Final hourly rate or salary
Work performed
Upload resume
Max. file size: 25 MB.
Upload cover letter
Max. file size: 25 MB.
How did you hear about this job?(Required)
- Advertisement
- Friend
- Relative
Consent(Required)
Applicants are considered for all positions without regard to political affiliation, disability, color, race, creed, national origin, religion, gender, age, ancestry, disability, handicap, marital status, status as a qualified disabled veteran, veteran status, or sexual orientation.

I certify that the facts contained in this application are true and complete to the best of my knowledge
and understand that, if employed, falsified statements on this application or any other pre-employment
documents shall result in termination when discovered. I authorize you to obtain an investigative
consumer report and/or a report or investigation from any law enforcement agency which may include
both general and personal information about me. I authorize investigation of all statements contained
herein and authorize the references listed above to give you any and all information concerning my
previous employment and any pertinent information they may have, personal or otherwise, and release
all parties from all liability for any damage that may result from providing same to the City.

In consideration of my employment, I agree to conform to the rules and regulations of the City and
agree that my employment and compensation can be terminated, with or without cause, and with or
without notice, at any time, at the option of either the City or myself and without notice or liability for
wages or salary except such earned at the date of such termination.

In the event that I am employed, I understand that regardless of the shift and job that I am first
assigned, I may be required to accept a change of job or shift depending on my demonstrated skills after
employment and the needs of the City. I consent to take any and all physical or medical examinations,
including blood and urine or other tests for alcohol and drugs, requested by the City in connection with
the processing of my application for employment and further agree to take any such physical or medical
examinations requested by the City during my employment if I am offered and accept a job. I
understand that such an examination may be needed in order to determine my competence to perform
the job or work for which I was hired, or to identify any physical or mental condition which may be
relevant to my job performance. I understand that refusal to submit to any physical or medical
examination ordered by the City will result in rejection for employment or for disciplinary action up to
and including immediate discharge. I further understand that any information obtained through such
exams may be retained by the City and is exclusively the City's property. I also understand that the
examinations will be performed by medical personnel, clinics, or laboratories qualified to do the
necessary work and costs for such examinations will be borne by the City.
I agree and consent.
Terms and conditions(Required)
By typing your name below and clicking on “I Agree” below, you acknowledge and agree to the
following:
• I have read, understood, and agree to the terms and conditions of the City of Effingham Employment
Application;
• I agree to submit and proceed with the City of Effingham Employment Application through electronic
means;
• I agree that my electronic signature is the equivalent of a manual signature and that the City of
Effingham, Illinois, may rely on it as such in connection with any and all agreements that I may enter into
with the City of Effingham, Illinois, and any documents I electronically sign for the City of Effingham,
Illinois;
• I acknowledge and agree that it is my obligation to immediately advise the City of Effingham, Illinois of
any change in my electronic address (i.e. email address);
• I acknowledge and agree that it is my obligation to immediately advise the City of Effingham, Illinois, in
the event I withdraw my consent to use electronic means for the application and/or account;
• I acknowledge and agree to the terms and conditions contained within the Online Application E-
Signature and Electronic Disclosure Agreement
• I acknowledge and agree that the various security and verification procedures adopted by the City of
Effingham, Illinois, in connection with the City of Effingham Employment Application, as well as any
other documents that I will affix my electronic signature constitute reasonable and secure security
procedures and that all signatures are attributable to the person whose name is typed below;
• I acknowledge and agree that the individual completing this City of Effingham Employment Application
is the individual from whom the application is being requested and whose name is typed below.
If you understand, accept, and agree to the policies, terms, and conditions set forth above (and as
attached), then type in your name and click on the “I Agree” button below to acknowledge your
acceptance and agreement. By typing your name below, you understand that you are electronically
signing this document and are agreeing to all of the policies, terms, and conditions set forth above. You
further understand that the City of Effingham, Illinois, will rely upon your electronic signature to the
same extent as if you had signed this document in ink. If you do not understand or accept or agree to
the policies, terms, and conditions set forth above, then do not click on the “I Agree” button and exit
this site.

Online Application E-Signature and Electronic Disclosure Agreement:
This Online E-Signature and Electronic Disclosures Agreement (“eSign Agreement”) Applies to All
communications, documents, disclosures ( “Communications” ) and electronic signatures related to the
products, services, and accounts offered or accessible through this online City of Effingham employment
application process for all applicants, co-applicants and other individuals listed on the City of Effingham
employment application, or any and all other application or form including beneficiaries and authorized
users, if applicable.

Agreement to Conduct Transaction by Electronic Means:
You agree to conduct the transactions offered through this online application process by electronic
means and acknowledge that all documents, disclosures, forms and other information related to such
transactions completed through this online process will result in valid and legally binding agreements.
You also agree that you have adequate access to a computer or device with sufficient internet
connectivity to conduct these transactions online.

Agreement to Use Electronic Signatures:
You specifically agree that any electronic signatures that you provide through this online process are
valid and enforceable as your legal signature. You acknowledge that these electronic signatures will
legally bind you to the terms and conditions contained in the related documents just as if you had
physically signed the same documents with a pen.

Agreement to Receive Disclosures Electronically:
You agree to receive all legal and regulatory disclosures and other communications associated with any
of the account applications or transactions available through this online application process through
electronic means including this web based electronic interface and email.

Withdrawing Your Consent:
You may withdraw your consent to this online eSign Agreement and electronic signature at any time by
not clicking on the “I Agree” button on the page prior to completing the application process. If you
withdraw your consent, by not clicking on the “I Agree” button before the account application process is
complete, we cannot accept and process your application.

To contact the City of Effingham:
City of Effingham
201 E. Jefferson Avenue
P.O. Box 648
Effingham, Illinois 62401
or
DPresley@EffinghamIL.com
I agree to the terms and conditions.
Electronic signature (your name)(Required)
First Last
Today's date(Required)
CAPTCHA

Name	Email	Phone

School name	Grade / years completed	Diploma / degree	Course of study	Honors Received

Current or most recent employer information

Previous employer information

Previous employer information

Previous employer information