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2. APPLICATION FOR EMPLOYMENT CITY OF LE MARS, IOWA
4. DATE*
   DATE
7. POSITION APPLIED FOR*
9. First Name*
10. Last Name*
12. Street Address*
14. City*
15. State*
16. Zip*
17. Phone Number*
19. Email Address
21. Are you 18 years of age or older?*

    1. Yes
    2. No
22. Date Available for work:
    Date Available for work:
26. Have you worked for the City before?

    1. Yes
    2. No
27. Department
29. If Yes, date of hire?
    If Yes, date of hire?
30. Date of termination?
    Date of termination?
34. Do you have a legal right to work in the United States?

    1. Yes
    2. No
36. Are you a Military Veteran as defined in Iowa Code Section 35.1?

    1. Yes
    2. No
40. Do you currently have a valid Driver's License?

    1. Yes
    2. No
41. Commercial Driver's License?

    1. Yes
    2. No
42. If yes, CDL Class
46. Have you ever been convicted of a felony?

    1. Yes
    2. No
47. If yes, describe
49. NOTE: A conviction does not automatically eliminate you from City employment since nature of the crime and type of job for which application is made will be considered.
53. List applicable equipment you are qualified to operate*
57. Please check all office operations that apply:

    1. Keyboarding
    2. Calculator
    3. Copier
    4. Microfilm Equipment
58. Other office equipment you are capable of operating:
62. QUALIFYING SKILLS AND/OR EXPERIENCE
64. Briefly describe any additional skills or experience you have which would qualify for this position:
66. EDUCATION AND/OR TRAINING - Please list High School, College, Trade or Business Schools attended.
68. Name and Location of High School:
69. Highest Grade Attended
70. Graduated

    1. Yes
    2. No
71. Currently Attending

    1. Yes
    2. No
73. Name and Location of School
74. Highest Grade Attended

    1. Associate
    2. Bachelor
    3. Master
    4. Doctorate
75. Graduated

    1. Yes
    2. No
76. Currently Attending

    1. Yes
    2. No
78. Major or Degree
80. Name and Location of School
81. Highest Level Attended

    1. Associate
    2. Bachelor
    3. Master
    4. Doctorate
82. Graduated

    1. Yes
    2. No
83. Currently Attending

    1. Yes
    2. No
85. Major or Degree
87. Name and Location of School
88. Highest Level Attended

    1. Associate
    2. Bachelor
    3. Master
    4. Doctorate
89. Graduated

    1. Yes
    2. No
90. Currently Attending

    1. Yes
    2. No
92. Major or Degree
96. EMPLOYMENT - EXPERIENCE: Give complete employment record for the last ten (10) years, starting with your present or last employer. PLEASE NOTE THIS SECTION MUST BE COMPLETED EVEN IF A RESUME IS SUBMITTED.
98. Company Name & Address
99. Dates of Employment
    Dates of Employment Start Date

    —

    Dates of Employment End Date
100. Job Title & Reason for Leaving
101. Description of Duties
103. Company Name & Address
104. Dates of Employment
     Dates of Employment Start Date

     —

     Dates of Employment End Date
105. Job Title and Reason for Leaving
106. Description of Duties
108. Company Name & Address
109. Dates of Employment
     Dates of Employment Start Date

     —

     Dates of Employment End Date
110. Job Title & Reason for Leaving
111. Description of Duties
115. REFERENCES
117. First, Last Name
118. Phone Number
120. EMail Address
122. First, Last Name
123. Phone Number
125. Email Address
127. First, Last Name
128. Phone Number
130. Email Address
134. I hereby certify that all statements in this application are true. I understand that if any of the above statements are not true, this application may be rejected and may cause any appointment to a position to be rescinded. I hereby authorize the City of Le Mars to contact any of the employers listed above to verify employment and work record. I authorize the City of Le Mars to verify and investigate through law enforcement agencies the status of my driver's license and to conduct any background check it deems necessary.
136. 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.
138. Electronic Signature
140. Affirmative Action - Equal Opportunity Employer
Leave This Blank:


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

     This field is not part of the form submission.

144. Submit Submit and Print

* indicates a required field