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Please Prtnt

City of Elephant Butte 103 Water St.

Elephant Butte, NM 87935 (575) 744-4892

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Deparrmenr;

Narnc: ___ _ ____ _ ___ ____ _____________ Applicanr ID# - - -------Last First Middle

Address --~-~-------------~-~~-------------------~--[ily St;ite ZlP Cod;

Telephone # _,__ _ _,_ _____ Cellular/Other Phone# _,( _ _ ,,__ __ E-mail Address ___________ _

Position{s) applied for ----- -------------------Dare of application __ ..._ ____ _

Referral Source (Please check the appropriate category and list the source.)

D w.ilk-In ___________ ___ _

D Employee _______________ _

D Advertisement ________________ _

D Company's Website: _ ________ _____ ~

D Other Internet ______________ _ _ _

AM If necessary, best time to call you is.................. .. . PM

0 Home 0 Cellular/Other May we contact you at work? ...................... ........... ... D Yes D No

If y-es, work number and best time to c...tlJ:

If you are under 18 and it is required,

AM PM

can you furnish a work permit? .......................... .. ..... 0 Yes 0 No

If no, please explain:---------------

Have you submirred an application here before? .... .... 0 Yes 0 No

If yes, ~ive date(s) and position(s): ---------

Have you ever been employed here before? ................ 0 Yes D No

If yes, give: dares: From / / To / /

Is chls application a request for reemployment following an extended military leave of absence from this company? ..................................... .. ..... 0 Yes 0 No

Are you legally eligible for employment in chis country? ..... ........... .................. ....................... 0 Yes 0 No

Date available for work......................... .............. / / What is your desired salary range or hourly rate of pay?

$-~-~------- Per ______ __ Type of employment desired: D Full-Time D Parr-Time:

0 Educational Co~Op 0 Seasonal DTemporary

Will you relocate if job requires it? ............................ 0 Yes 0 No

Will you travel if job requires ir? .. ....................... ........ 0 Yes 0 No

If they have been explained to you, are you able m meet the attendance requirements of che position? ..... 0 NIA 0 Yes 0 No

D School ---------~---~---~~

DJobFair _ _ _ ____ ~~-~----~ 0 StaffingAgency ______________ _

0 Government Employmenr Agency _____________ _

D Ocher ---------- ------

Will you work overtime if required? ........... ............... 0 Yes 0 No

If no, please explain: - -------------

Arc: r._~u able: to perform the: "essential functions" of rhe job for which your.arc applying (with or without reasonable accommodation)? This' question is not designed to elicit information about an applicant's dfsab1lity. Please do ~t provide information about the existence of • disobility, portkul<ir occornmodotion, or ,Whether accommodation fa necessaiy. These issuGS may be addressed at a later stage to the

1ptent pennitted by law.

D Yes D No D Need more information about [he job's "essenciaJ functions" co respond

Driver's license number required if driving may be required in the job for which you are applying:

State ____ _

Have: you ever been bonded? ..................................... 0 Yes D No

Answeiing "yes" to the follo wing question does not constitute an automatic bar to employment. Foctors such as date of the offense, seriousness and nature of the violation, rehabll1tation and position applied for will be taken into account.

Have: you ever pleaded "guilty" or "no comest'' ~o or been convicted of a crime? .......... ..... .................. .... ,. 0 Yes D No

If yes, please provide date(s) and details: _ _ ____ _

Have you emered inro an agreement with any former employer or other party {such as a noncompetition agreement) that might, in anr..way, restrict your ability to work for our company? ........... 0 Yes U No

If yes, please explain: ___ __________ _

AN EQUAL OPPORTUNITY EMPLOYER

Explain any gaps in your employment, other than those due to personal illness, injury or disability.

If not addressed on previous page, have you ever been fired or asked to resign from a job? .. ................................................. ..... D Yes D No

If yes, please explain: ------------------------------------

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you arc applying:

Computer Skills (Check appropriate boxes. Include software titles and years of experience.)

D Word Processing Years: 0 lmerner Years; ___

0 Spreadsheet Years: 0 Other Years; ___

0 Presentation Years: D Orher Years; ___

DE-mail Years: D Other Years: ___

Starting with your most recent school attended, provide the following information.

0 Diploma Cl GED ODeg1te _____ _ D Ctrtifi~atlon ____ _

OOther

0 Diploma 0 GED

D Degree------0 Certifi~l:ion ____ _

0 0tli~r

CJ Dlploma CJ GED

Cl Degree------OCertifimion ____ _

OOthOI

List names and telephone numbers of three business/work references who arc not related to you and arc not previous supervisors. If not applicable, list three school or personal references who are not related to you.

(

SS#

We will use th.ls information only for employment purposes and make reasonable efforts to safeguard your privacy.

To whac job-related organizations (professional, trade, c:tc.) do you belong? Exclude memberships that would reveal race, color, religion, sex, national origin, clti%enshlp, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

List special accomplishmencs, publications, awards, etc. Exclude information that would reveal race, color, religion, sex, national origin, citizenship, age. mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

In your currenc or a previous job, have you ever writcen inscrucdons or directions ro be followed by employees or customers?

D Yes 0 No 0 Nor Applicable

Ifyes,pleaseexpl~n:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Is there any oilier job-relaced information you want us co know abouc you? ___ ___ _ ____________ _ ____ _

I certify chat all information I have provided in order 10 3pply for and s~rc work wich chis employer )1 true, complete :i.nd corttcL

I expl'C$$1y authorize, without rcscrv:atlon, the employer, irs reprcscnrnive1, employees or agencs 10 cont3cc :i.nd obtain informarion from all refercnc.es (personal and profmion.U). employerf, public agtnc:lcs, licensing auchoriries and cduc:;icional ln$tltutloru :tt1d to od1erwlsc verl{f che accuracy of all information provided by me in rhi1 applic:;ition. rc.ium~ or Job lnmvlcw. I hereby waive any and all rights 11nd cl~ims I may have ttgardlng the employer, its agcn'ts, employeC$ or ll:pre.$enrativcs, for sec.king, g:itherlng and using truthful and non­defamatory information, in a lawful manner. in the employment process and all other persons, f~rpomions or org.inlutloru for furnishing mch lnformalion about me.

I underst;ind that thlt employer docs nor unlawfully discriminate in employment ond nl) l(uc;iton on thlt appllcarion is used for rhe purpose oflimiting or eliminating any applio;;ant from conslderadon for employment on any basis prohibited by appllable local, sme or federal lay,W

I undcrsrand char this application remains current for only 30 days. Ar che conclusion of thar time, ifl have no1 hc:o1rd ftom the employer and stilt wlth ro be coruldettd for employment, ir will be necc:ssaI}' for me ro reapply and Ill! O\lt :i. new 3pplic'1cion.

lfl am hired. I i.ir!dmtand that I am ftte to n:slgn ar any time, with or without <:au.!c and wirh or without prior nodcc, and the employer reserves chc same right to mminate my employment at any lime, with or without cause and with or wilhout prior notice, except u m3y be required by law. This application docs not constitute an agrccmenr or contr.u::t for employmcnr for any specified period or definite dumion. I undersc:i.nd that no supervisor or representative of chc employer is audioriied to make any usur.inCCJ ro the conuuy and that no Implied oral or written agrcemenrs wnmiry to the foregoing express language arc valid unless they arc in writing and signed by the employer's president.

I also undemand tha1 if I am hired, I will be rcqu.lrcd co provide proof of identity and legal amhoril<!tion 10 work In the Unhcd St3rcs and chat federal lmmlgrallon laws require me co complete an 1·9 Forn'I in thi$ reg:ird.

Thjs Compa.ny doc.t not colcmte unlawful discrimination in its employment pnic'ticcs. No question on clW appUcadon ls used for the purpose oflimiting or ~cludlng IU\

•ppUct11t from con.sldenclon for employment on the b"'b of his or !tu SI!%, n ee, color, tdlglon, national orii;tn, ~itiun1hjp, "gl:• diJabj]jty; or any other protected Jt:ltuS under o.ppllcablc federal, state, or local law. Tim Company Uk~c dou not tolerate harusment baaed on·~ I'll~ ~olor, religion, national origin, citixcn1hlp, a.ge, dlnbilicy, or any other protcaed mtw. Exam plea of prohibib!d hii.t3Ssmcnt Include, but arc not limited to, unwckome phpieal cont:ttt, olFCJUive gc.ttUttS, wiwelcotno comments, Jokes, epithets, threats, illflllU, mune·calllng, negative stereotyping, possession or displll)' of derogatory picturc.t or other gttphlc maccrl:W, and any othu words or condu« that demean, stigmatiu, I.nti.m.idatt, or single out a person bcc:aUie of hi1fher membership in a prvw:ted aucgory. Harassment of our cmplo~cs Is sttictly prohibited, whether it ii wuunimd by a man:tgtt, coworker, subordinate, or non•employce (such u a Ye11dor or Cllitomer). The Company takes all wmplaints ofbM1Umcnt seriously and all compWnu will be i.nVHdgatcd promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented ln any respect, will be sufficient cause to (i) elimin~te me from further consideration for employment, or (!I) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I cenify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Date _ _..../ _ __./'---

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